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Parents do not stop providing assistance to their children when they reach maturity or when they establish their own households . Rather, research has shown that emotional support, advice, practical assistance, and financial help from parents play an important role in adult children's lives . Further, providing support to adult children appears to have implications for parents' well-being . To date, research has examined support exchanges between parents and adult offspring by focusing on support that occurs within one parent-child dyad in a family or by aggregating all help given by a parent . This is, in part, due to the fact that studies often assess support from the adult children's reports , not reflecting support to multiple children. Also, studies using parents' perspectives typically aggregate support to all children, or select one focal child . Yet, most parents are involved in support exchanges with more than one grown child . Decisions to provide assistance and support to a member are affected by other relationships within a family ; the help that a parent gives to one child may potentially come at a cost to what can be given to other children. Thus, it is important to consider multiple family members to understand how middle-aged adults divide their time and energy in supporting grown children . In this regard, an emerging perspective emphasizes the importance of patterns of interactions within families and incorporates multiple dimensions of interactions to characterize typologies at the level of family . This is consistent with families as a system; the family is an organized whole, functioning as a totality . So far, most studies have used a variable-centered approach by examining "factors" contributing to differences in the amount of support given to each child . That is, researchers assume the family as a summation of individual members and examine individual variables such as offspring gender and income, rather than looking at the composition of the family as a whole functioning unit. Although the variable-centered approach is useful to test theories regarding parental motives at the child level, this may not be helpful to describe how parents distribute their resources among adult children at the family level -as naturally occurring. To fill the gap of the literature, using a typology approach, we addressed "patterns" of within-family differentiation in parental support more directly, while also examining family-level characteristics. --- How Do Families Differ in Parental Support? In this study, we examined how middle-aged adults provide support to "multiple" grown children, including different types of support from the perspective of parents. On the whole, parents differ in the level of support they provide to their children; some parents may provide more support to their adult offspring than other families . Parents also differ in the degree to which they tailor support to specific grown offspring; some parents may differentiate among their children in providing support, whereas other parents may provide support to their children equally . Thus, to classify patterns of parental support at the "family" level , we considered two within-family indicators: mean level support in the family and differentiation among children. Prior research has identified individual and familial characteristics that explain between-family differences in the levels of intergenerational support . As a way to address between-family differences in intergenerational ties, studies have also utilized a typology approach by grouping people into distinct classes . Using support indicators exchanged between parents and adult children, Hogan and colleagues identified four support patterns; low exchanges, high exchanges, high giving, and high receiving. Van Gaalen and Dykstra found five patterns of parent-adult child relationships by combining contact, support, and conflict; these typologies differed in emotional qualities as well as in levels of support. However, most typology studies have considered differences only in levels of support to distinguish patterns. Moreover, these studies have addressed "dyadic" patterns of exchanges occurring within individual parent-child dyads, so with little information regarding "family" patterns, including multiple relationships within families. Families also differ in how support is distributed across adult children . For example, some parents may be high in support overall, but differentiate among their children. Other parents may invest their support in one child and seek to give to others as well . Still, other parents may not give much to any of their children; differentiation is low, but so is mean level of support. Thus, the degree of differentiation in support that parents exhibit toward their offspring can be an important aspect characterizing adult families. Indeed, research on childhood suggests that the degree of parental differential treatment varies by family-level contexts, such as socioeconomic status, family structure, and family stress , even after controlling for child-specific characteristics . Recently, scholars have examined within-family variation among grown children in intergenerational ties . These within-family studies have examined theories regarding motives for parental support , focusing on "child-specific" levels of support and predictors . These studies, however, are not informative regarding between-family differences in the within-family differences in parental support . In other words, these studies have looked at whether some children have higher levels of support than other children, but they have not considered whether some parents are more likely to favor a particular child with more support , whereas other parents provide equally to all their children. Prior studies have found that grown children's emotional well-being was associated with the degree of parental differentiation in support within the family, with siblings who are favored reporting better well-being than siblings who are not favored . Thus, it is important to consider variability as well as mean level of support within a family. --- Why Do Families Differ in Parental Support? This study examined parental support to multiple children by combining the mean level and differentiation . We considered three sets of characteristics that may explain different patterns of parental support: parental resources, parental beliefs, and offspring characteristics. --- Parental Resources Research has documented that parental resources are positively associated with levels of support to adult children. Parent's socioeconomic status predicts financial support , though it is less clear whether parental SES predicts non-tangible support, such as help with household chores and child care . Parents who are in better health also provide more support to adult children . The presence of spouse may also offer support; married parents provide more support to grown children, compared to non-married parents . Finally, prior research has shown racial differences in parental support; White parents provided more support to grown children than Black and Latino parents . These differences appeared to be associated with racial differences in available resources . Thus, given that parental resources are associated with greater capacity to provide material support and better access to information and advice for adult children , we expected parents with more resources to provide a higher mean level of support to their adult children overall. Regarding differentiation of parental support among adult children, we expected negative associations with parental resources . According to resource depletion theory , parents who have limited material resources are likely to show differential investment across offspring . Under economic crisis, families often allocate their limited resources across family members disproportionately as a part of family strategies to ensure their physical and economic survival . In addition to material resources, parents who are less available psychologically tend to show more differentiation toward young children . Thus, parents who have fewer psychosocial resources also may differentiate more among adult offspring. --- Parental Beliefs About Helping Offspring The ability of parents to provide support does not necessarily mean they provide such support to grown children. Actual support behaviors may be conditioned by beliefs about obligation toward family members . Research has shown that parents feel different levels of obligations toward adult children depending on their characteristics, such as family structures and race/ethnicity . Adults who showed stronger feelings of obligations tended to provide more support to their offspring . Thus, we hypothesized that parents with stronger feelings of obligation toward offspring will provide more support overall. Regarding differentiation among offspring, however, we did not specify a hypothesis for parental obligation; parents who feel more obligated to support their offspring might differentiate less between offspring due to a general norm of obligation applying to all children, or they might differentiate more if there is a child in need, since they feel more obligated to help. In Western countries, strong norms call for parents to treat their children equally . Despite these cultural norms, studies find that parents differentiate among their adult children in terms of emotional closeness and support . Yet, studies have not examined whether the degree of differentiation reflects parental beliefs about equal treatment directly. We only found one study examining parental values/beliefs to explain differentiation among adult children ; more religious mothers were less likely to have a preference for one child in terms of emotional closeness. Here, we asked whether parents who have stronger beliefs about equal treatment are less likely to show within-family differentiation in support among grown children. --- Offspring Characteristics Offspring characteristics may be associated with overall levels and differentiation in parental support across offspring. Because this study examined between-family differences in patterns of parental support, we focused on aggregate characteristics regarding the composition of grown offspring. Prior research has established that parents invest more resources in their biological children compared to step or adopted children . It appears that the differences between biological and non-biological children in parental support reflect differences in biology, family structure, and past history of parent-child ties. That is, parents typically give more to their biological children than to stepchildren for a variety of reasons . Thus, we expected that middleaged parents with only biological children would provide more overall support to offspring, compared to parents with at least one step or adopted child. Also, parents with an adopted or step child may differentiate among their children more in providing support -due to the heterogeneity of offspring composition. Children in larger families also tend to receive less support from parents because of depletion of parental resources for any given child . Further, a larger family size is related to more opportunities for differentiation of parental support . Thus, we predicted that larger family size would predict lower levels of support as well as greater differentiation in support across members. We considered age and gender composition of offspring. Feminist theories suggest that daughters retain stronger ties to their families of origin and receive more support from parents . Thus, having a daughter may be associated with higher overall levels of parental support. And, when offspring are all the same gender, there may be less within-family differentiation in parental support . Parents also give more support to younger adult children, reflecting their needs . Therefore, we expected that parents with younger offspring would provide more support overall. Further, bigger age intervals between siblings may represent heterogeneity in life stages, which may result in greater parental differentiation among offspring. Finally, provision of support is facilitated or limited by geographic distance. Having any coresiding child will increase the overall levels of parental support . Also, we expected that presence of a coresiding child to result in inequitable support across offspring -due to extensive support to the coresident offspring. In sum, this study addressed patterns of parental support at the family level by creating a typology based on mean level and differentiation across multiple offspring. To predict typology membership, we considered a range of family characteristics, including parental resources, parental beliefs, and offspring characteristics. We expected that more parental resources would be associated with patterns reflecting higher mean levels of parental support, but less differentiation across offspring. Regarding parental beliefs, we expected that stronger feelings of parental obligations would be associated with patterns with higher mean levels of parental support and stronger beliefs of equal treatment would be associated with less differentiation of parental support among offspring. We also considered aggregate levels of offspring characteristics predicting patterns of parental support. --- Method --- Sample Data were from the "Family Exchanges Study" . The original sample included 633 middle-aged parents who had at least one child over age 18 and one living parent in the Philadelphia Metropolitan Area. The study identified potential participants via listed samples from Genesys Corporation supplemented with random digit dialing within geographic area codes. Utilizing Computer-Assisted Telephone Interviews , we surveyed the participants for approximately 1 hr in 2008. Participants responded to questions about their own background and each of their grown children. This study included a subsample of 431 middle-aged parents who had at least two adult offspring to examine within-family patterns among multiple offspring . The subsample did not differ from families who have one offspring based on parental characteristics , except age -older parents were more likely to have more than one child . Regarding offspring characteristics, families with multiple adult children were more likely to include nonbiological offspring than families with one child . Also, families with multiple adult children showed lower mean levels of support given to offspring than families with one offspring . --- Measures --- Support provision We assessed support parents provided to each grown child using six items from the Intergenerational Support Scale : emotional support, practical assistance, advice, companionship, listening to talk about daily events, and financial support. Parents provided separate ratings of each type of support given to each child. Mean scores across the six types of support were calculated . We used the total support index for ease of interpretation, but each type of support was examined separately in post hoc analyses. --- Parent's resources Parents reported their demographic characteristics representing parental resources: years of education, household income , marital status , employment status , and race/ethnicity . Regarding parental health, parents rated their physical health on a 5-point scale from 1 to 5 . We assessed depressive symptoms using five items from the Brief Symptom Inventory . The items were rated from 1 to 5 , and a mean score was calculated . Among parental demographics, we also considered parent age and gender . Although we did not hypothesize that these two demographics may represent parental resources, we included parent gender in the model as a control, given gender differences in supporting behaviors . Due to a high correlation with the youngest child's age , we did not include parental age in the model. --- Parent's beliefs about helping offspring We considered two beliefs about helping offspring: obligation and equal treatment. For obligation toward offspring, we asked participants how often parents should provide their adult children the six types of support , rated on a 5-point scale from 1 to 5 . Mean scores of the six items were computed . For beliefs about equal treatment, parents indicated the extent to which they try to give each child the same amount of help, regardless of need, rated on a 5-point scale from 1 to 5 . --- Offspring characteristics Parents also provided information about each grown child, including their relationship to that child , age, gender, and living arrangement. Using information about each offspring, we created aggregate variables representing composition of offspring in the families. We considered whether all children are biological . For offspring age, we included: the age interval between the eldest and youngest children and age of the youngest child. Offspring gender composition included: whether all children are the same gender and whether there is any daughter . Also, we considered whether any grown child resided in the same household as the parents . Finally, the number of grown offspring in the family was included. --- Analytic Strategy --- Description of support given to offspring We first looked at the intraclass correlations to describe the amount of support given to multiple offspring . ICC is the proportion of the variance due to between-family difference among the total variance which is composed of withinand between-group variances. From a two-level multilevel model with no predictor , the ICC was calculated as the random intercept variance divided by the total variance . Thus, 1 -ICC indicates the proportion of within-family variability. Next, to represent within-family patterns of support among grown offspring, we calculated two summary scores from the raw scores of support given to each offspring : mean level and differentiation . We looked at the descriptive statistics of these within-family indicators, including correlations between them. a Rated on a 6-point scale from 1 to 6 . b Rated on a 5-point scale from 1 to 5 . c Mean of five items rated on a 5-point scale from 1 to 5 . d Mean of six items rated on a 5-point scale from 1 to 5 . e Rated on a 5-point scale from 1 to 5 . --- Classification of within-family patterns of support We classified family patterns of support given to multiple children based on mean level and differentiation within the family. A latent profile analysis was conducted using Mplus 7.3 . Before applying LPA, we transformed the original scores of mean level and differentiation into standardized scores for ease of interpretation. We selected the best model based on model fit indicators, including the likelihood ratio chi-square test statistic, the Bayesian Information Criterion , the Lo-Mendell-Rubin likelihood ratio test , and bootstrapped likelihood ratio test . --- Prediction of within-family patterns of support After determining the optimal number of patterns, we examined which family characteristics differentiate the derived family patterns. Specifically, a multinomial logistic regression model was estimated with three sets of predictors . For the dependent variable , we used the "most-likely" class variable which was constructed via the latent class posterior distribution. To correct the measurement errors between the "latent" class variable and the "most-likely" class variable, the misspecification rates were considered in the multinomial logistic regression model. This analysis was performed using R3STEP option in Mplus 7.3 . --- Results --- Description of Support Given to Multiple Offspring We first looked at how much differentiation exists in amount of support given to each offspring . Consistent with prior studies , the two-level ICC revealed substantial within-family differentiation in support parents provided to their children. For the total support index , within-family variability showed a larger portion of variance than between-family differences . Thus, offspring within the same families differed in support received from parents somewhat more than they differed from offspring from other families . Proportions of within-family variance were similar across each type of support . We also examined bivariate associations between mean level support and differentiation within families . For total support, there was a negative association between mean level and differentiation ; parents providing more support to adult offspring were less likely to differentiate among their offspring. For each type of support, tangible forms of support showed positive correlations for within-family means and differentiation, whereas non-tangible forms of support had negative correlations, except companionship. Thus, in general, parents who gave more tangible support also differentiated more among their offspring, but parents who gave more non-tangible support did so fairly equally to each offspring. --- Classification of Within-Family Patterns of Support We classified families into distinct patterns based on the average level and differentiation in "total" support given to adult offspring within families. The LPA identified four latent patterns of support as optimal . Figure 1 demonstrates the mean scores of the within-family indicators for each pattern. As a post hoc analysis, we also repeated LPA using the average level and differentiation of each type of support given to adult offspring, and found similar results as ones from total support index . characteristics). Table 3 shows the effects of family characteristics on membership in these within-family patterns. All variables were entered simultaneously in the model; results reflect the effect of each variable when all other covariates are held constant. The first pattern was used as a reference pattern. The second pattern of families showed significant differences only in offspring characteristics, compared to the reference pattern . Specifically, these families were more likely to have non-biological offspring, larger family size, and bigger age gaps between offspring. In the third pattern of families , the parent was more likely to be father and have lower feelings of obligations toward adult offspring. In terms of offspring characteristics, these families were more likely to include non-biological offspring and the children were more likely to be older and live in separate households from parents. Finally, the fourth pattern of families showed that the parent was more likely to be re/married, ever divorced, and show higher levels of depressive symptoms and lower beliefs about equal treatment. Also, the children were more likely to be younger and show bigger age gaps between offspring -compared to the reference pattern. --- Discussion Research has indicated complexity in intergenerational ties, and one source contributing to complexity is multiple relationships within families . However, less is known about how families allocate their finite resources to meet needs of multiple members within families. In an attempt to understand multiple relationships at the family level, we created profiles of parental support given to each of adult children, using mean levels and differentiation among offspring. Prior studies on intergenerational support have focused on only the levels of support -either overall levels across offspring or child-specific level to 6 . b Rated on a 5-point scale from 1 to 5 . c Mean of five items rated on a 5-point scale from 1 to 5 . d Mean of six items rated on a 5-point scale from 1 to 5 . e Rated on a 5-point scale from 1 to 5 . *p < .05. **p < .01. ***p < .001. Gaalen & Dykstra, 2006), but we added another dimension, differentiation in parental support to capture dynamics of between-and within-family differences in support. --- Within-Family Description of Parental Support On the whole, differences within families were greater than differences between families in parental support. This is consistent with the within-family difference literature, emphasizing the variability in support and relationship qualities among multiple grown children . Associations between differentiation in support and average support to children in the family differed by types of support. Interestingly, parents who provided more tangible support were more likely to provide that support unequally across offspring. By contrast, for non-tangible support , parents providing a greater amount of support tended to do so equally across offspring. Provision of tangible support may be contingent on specific needs of offspring. Further, material and time resources are finite, forcing parents to focus only on specific offspring . --- Within-Family Patterns of Parental Support We created four family patterns as combinations of mean levels and differentiation in parental support. The derived patterns suggest that amount of support is not the only factor that distinguishes families -rather the extent to which parents differentiate among their adult children can be important to distinguish families in their supporting behaviors. Two patterns showed overall high and low mean levels of support respectively, but did not show much differentiation across offspring. About half of families were high in support , while 17% of parents were low in support , consistent with prior research showing that majority of parents continue providing assistance to their adult children . Thus, despite differences in the mean levels , support was equally distributed across offspring in these two patterns in the substantial proportion of these families . The other two patterns were characterized by high differentiation across adult offspring, along with medium to low mean levels of support respectively. In these families , support provided to each offspring differed a lot, so the mean levels appear to represent just the middle points of support between offspring who get the most and the least. Thus, considering only the levels of support may not be enough to reveal dynamics within families and differences in support patterns between families. Indeed, these findings suggest that research examining level of support to only one focal child or aggregate children may miss the other extreme of support, possibly within the same family. --- Prediction of Within-Family Patterns of Support We examined factors that predict membership of the derived patterns, including parental resources and beliefs, and offspring characteristics. Regarding parental resources, two variables were associated with pattern membership . Specifically, parents who reported more depressive symptoms were more likely to show "low support-very high differentiation." This is consistent with expectations that more resources would be associated with providing support frequently and equally across offspring . The support measure included several types of non-tangible support , which may partially explain why parents' psychosocial resources appeared as more important in determining patterns of parental support -compared to economic resources . Parental marital status was also associated with pattern membership; re/married parents and parents who have ever divorced were more likely to show "low support-very high differentiation." This finding was not consistent with prior research showing higher support from married parents . Genetic relatedness of offspring in the models may have overlapped with the "married" parents -thus, the effect of marital status may actually represent effects of "remarried" parents. Remarried parents typically provide less support to grown children than do parents married to the child's other parent . Nonetheless, we also included ever-divorced in the models, which should have partially controlled for the remarried group. Future research should seek to better explain why married parents would fall into this pattern. Among parental demographics, we also found a significant effect of parent's gender, although gender was not a predictor for parental resources. Fathers were more likely to show a pattern of "low support-low differentiation." This is consistent with gender differences in supporting behaviors in adult families . For parental beliefs, both beliefs about obligation and equal treatment were associated with pattern membership. As expected, parents with stronger feelings of obligation toward adult offspring were less likely to show a pattern of "low support-low differentiation." Interestingly, our finding also showed that parents who harbored stronger beliefs about equal treatment were less likely to have a pattern with "low support-very high differentiation." Although prior studies examining normative beliefs have mainly focused on filial obligation to assist aging parents or parental obligation to support adult children , beliefs about specific motives and manners of helping family members may be involved in support . Finally, except gender composition, the composition of offspring in the family was significantly associated with patterns of parental support. Specifically, families with all biological children were more likely to show "high supportlow differentiation" . Also, larger families were more likely to have a pattern of medium support and high differentiation . With regard to offspring age interval, families with bigger age spaces between offspring tended to show patterns with high differentiation . Given that age is one of the central factors reflecting offspring's needs , this finding may show that parents are providing support, responding to differences in needs among children. Families with older children were more likely to have low mean levels and less likely to have very high differentiation, suggesting these older grown children all received little parental support . Families with any coresiding children were less likely to show low support and low differentiation. These findings regarding offspring characteristics suggest that the patterns of parental support given to adult children reflect recipients' characteristics . Some limitations of this study should be noted. First, we included offspring characteristics in aggregate, and did not specify conditions for each offspring that may lead to parental differentiation. Given that exchanges of support are contingent on needs of receivers , individual characteristics of each child should be considered for patterns of parental support. Second, although we relied on reports of one parent regarding support given to each child, for a better understanding of family patterns, we might need to incorporate reports from other members in the families . Finally, the mean levels and differentiation within the same patterns did not differ by type of support, but it might be possible that the effects of some of the predictor variables can still differ between different kinds of support . Despite such limitations, this study is one of few to consider intergenerational support at family levels by incorporating both aspects of mean levels and differentiation and to investigate factors associated with family patterns of parental support. The existing theories and most empirical studies have used a child-parent dyad as the conceptual and analytical unit and provided only indirect evidence for variations within families. It would be important for future research to develop theories to explain dynamics between multiple members within families. --- The first pattern, "high support-low differentiation" showed a high mean level and low differentiation in the total support given to grown children. Adult offspring in these families received support from parents frequently, and the levels of support did not differ much across offspring . The second pattern, "medium support-high differentiation" had a medium mean level and high differentiation among offspring. Because the differentiation was high, some adult offspring in these families received a great deal of support, while others received very little, with medium levels of support from parents on average. The third pattern, "low support-low differentiation" was characterized by a low mean level and low differentiation in support. Offspring in this pattern received lower levels of support from parents at similar levels. The last pattern, "low support-very high differentiation" was characterized by a low mean level but very high differentiation among children. In this pattern, the parental support differed considerably across offspring, with perhaps one offspring receiving support while others received very little or no support. --- Prediction of Within-Family Patterns of Support Next, we conducted a multinomial logistic regression to differentiate these four types of families, using three sets of characteristics (i.e., parent's resources and beliefs, offspring --- Supplementary Material Please visit the article online at http://psychsocgerontology. oxfordjournals.org/ to view supplementary material.

Objectives: Families differ widely in the support they provide to adult offspring, both with regard to the overall level as well as the extent to which support is evenly distributed across offspring. This study addressed these dynamics by creating family profiles based on the average level and differentiation of support among children. We also examined demographic and psychological factors that predict typology membership. Method: We utilized data from 431 middle-aged parents (aged 40-60) with at least two adult children. Parents provided separate ratings of support given to each child. Latent profile analysis was applied to two indicators of within-family support: mean level and differentiation among offspring. Results: Latent profile analysis identified four patterns of parental support: (a) high support-low differentiation (52%), (b) medium support-high differentiation (26%), (c) low support-low differentiation (17%), and (d) low support-very high differentiation (5%). These patterns reflected distinct family characteristics, such as parental resources, parental beliefs (i.e., equal treatment, obligation), and offspring characteristics. Discussion: Our findings emphasize the need to capture dynamics of support exchanges among multiple offspring at the level of family.

Introduction Due to the increasing influx of female workers in Taiwan, concern has arisen with regard to the work-life balance of women, who traditionally have had more domestic responsibilities than men. With their growing participation in the labor force, the demands on women are becoming greater. In 1978, the female labor force participation rate in Taiwan was 39.1%, whereas in 1988 it was 45.6%. The latest data for 2019 showed it was 51.5% [1,2]. However, female workers were more vulnerable to physical and psychological symptoms than male workers in Taiwan [3]. Another survey for hospital staff in Taiwan also showed that when job position, work year, and daily work time were taken into consideration, female employees experienced more nervousness, nightmares, irritability, headaches, and insomnia than male employees did [4]. Studies have shown that female workers are generally more vulnerable to occupational stress than are male workers [5,6]. One study reported that stress levels of female managers were as high after work as during work, whereas among male managers, stress levels rapidly decreased when the working day ended [7]. Even when physical inactivity was controlled for in the analysis, gender differences existed in the presentation of burnout [8]. Exhaustion was consistently found to be more prevalent among women than men [9]. Work-to-family conflict has shown to be a longitudinal predictor of positive wellbeing among employees, even when controlling for social desirability bias [10]. Previous research has also documented work-related, non-work-related and stress-related outcomes [11]. Of particular interest to this study is the finding that WFC is more strongly associated with exhaustion in women than in men [9]. The value of these studies cannot be questioned; however, previous researches usually assume that WFC is an operative construct independent of cultural context. Since the term was coined in the West, a full picture of WFC in the Asian context requires an understanding of Eastern traditions and values. A previous study in Hong Kong found a non-significant relation between WFC and strain that was inconsistent with most findings in the West [12]. Another cross-cultural study found that workload was significantly associated with WFC among British study subjects, but not among Taiwanese subjects [13]. More studies in the East are needed to gain a fuller understanding of WFC. Burnout is an important issue in psychological literature. The term burnout is defined as a work-related mental health impairment comprising three dimensions: emotional exhaustion, cynicism, and inefficacy [14]. Burnout can result in adverse physical, psychological and occupational consequences. A systematic review of these consequences found that burnout is significantly related to physical health problems, such as type 2 diabetes, coronary heart disease, musculoskeletal pain, headaches, gastrointestinal issues, and so on; psychological effects include insomnia and depressive symptoms, among others; occupational outcomes extend from job dissatisfaction to absenteeism and new disability pension [15]. In addition, burnout was especially prevalent in certain occupations and among certain practitioners, for example physicians, of whom 46% had at least one symptom of burnout, according to a study in the USA [16]. Approximately one-third of physicians in the UK exhibited aspects of burnout [17]. Among the general population, a Finnish nationwide health survey found that 27.6% of general employees suffered from mild or severe burnout [18]. Due to the overtly adverse outcomes of burnout documented in these studies, which cover different areas of the world, this issue cannot be overlooked in studies on health and wellbeing among the labor force in Asia. An early identification of burnout may benefit employee health and reduce national health costs. Among European Union workers, high satisfaction with working hours has been associated with high satisfaction with work-life balance [19]. Since 2017, the Taiwan government has tried to decrease work hours by amending the Labor Standards Act; however, the effects are still too recent to be reflected in the literature [20]. According to data from the 2018 Organization for Economic Cooperation and Development and the Ministry of Labor in Taiwan, the average annual working hours in Taiwan are 2033. This figure exceeds those in Korea, Japan, and most countries in the OECD [21]. As with burnout, harmful effects of long working hours on health have been reported. One study found a substantial correlation between the number of working hours per week and the frequencies of both musculoskeletal disorders and psycho-vegetative complaints [22]. Several studies have suggested a potential association of exposure to long working hours with increased risks of cardiovascular diseases in general, and coronary heart disease and stroke specifically [23]. A systematic review of epidemiological evidence revealed that long working hours are associated with a depressive state, anxiety, and sleep disorders [24]. Strategies that might be applied to reduce the working hours in Taiwan have not yet been fully considered within occupational health care. Working long hours does not necessarily equal being unable to leave work on time. While the latter has consistently been regarded as a complaint pertaining to work strain, its effect on WFC or burnout has seldom been examined [25][26][27]. Most employees do not welcome compulsorily overtime; a more flexible work schedule and higher level of autonomy with respect to time management might alleviate complaints. Accordingly, some governments and employers have adopted friendly working arrangement policies, such as flexible work hours, longer lunch breaks and regulations against compulsory overtime [28]. To conclude that these initiatives result in an automatic reduction of working hours, however, would be erroneous. The work conditions are now fast-changing. "Work is a big part of our lives, but it's now easier than ever to let it take over. Mobile devices that are supposed to free us from the office can actually bind us to it" [29]. The boundary between work and life is becoming vague. The association between working long hours on a voluntary basis and employee perceptions is not yet clear. Therefore, both work hours and the difficulty in leaving work on time were considered simultaneously in the present study with the aim of exploring their effects on WFC and burnout. --- Materials and Methods --- The Participants and Recruitment Method The present study was carried out from 2013 to 2014 by the Center for Workplace Health Promotion, using a cross-sectional research method with convenience sampling. This study was conducted according to the Declaration of Helsinki and was approved by the Institutional Review Board of the Changhua Christian Hospital in Taiwan with a waiver of informed consent. Full-time female workers 20 years of age or older were recruited from six manufacturing companies in Central Taiwan to participate in this study. A consent form was distributed with the survey questionnaire. In total, 738 full-time Taiwanese female employees agreed to voluntarily take part in the study. A more detailed recruitment procedure is described in a previous paper [30]. --- Measures The survey questionnaire comprised several sections: personal information, family-and work-related questions, WFC, and burnout. Personal information included age, marital status, occupation, and economic status. Occupation was divided into two categories: white-collar and blue-collar [31]. Using a five-point Likert response format ranging from 1 "very poor" to 5 "excellent," the study measured economic status with one question: "How would you rate your economic status at the present time?" Family-related questions included the burden of parenting and the responsibility of housework. "Do you look after any child/grandchild under 12 years old at home?" was asked with a Yes or No response option. "How much housework do you take on?" was asked with a five-point Likert response format ranging from 1 "almost none" to 5 "almost all." Work-related questions included working hours per week and the difficulty in leaving work on time. Using a four-point Likert response format ranging from 1 "not difficult at all" to 4 "very difficult," the study measured the difficulty in leaving work on time with one question: "In general, how would you rate the difficulty in getting off work on time during the recent month?" The level of work-to-family conflict was measured using five questions adopted from the work-home interference scale [32]. This questionnaire was chosen for the present study because the items were not limited to married individuals. This scale assessed both time-based and strain-based conflict, and exhibited good internal reliability, with Cronbach's alpha equaling 0.820. This questionnaire used a four-point scale ranging from 1 to 4 . Higher scores indicated higher levels of WFC. The Cronbach's alpha was 0.703 in the present study. The Copenhagen Burnout Inventory was adopted to assess the level of burnout among respondents [33]. The CBI is a valid and reliable questionnaire measuring three burnout sub-dimensions: personal burnout , work-related burnout , and client-related burnout [33,34]. According to the theoretical rationale of the CBI, the three subscales can be used independently in accordance with the populations being studied [33]. For the purposes of the present study, two subscales of personal and work-related burnout were adopted to form a mean as general burnout. In this study, Cronbach's alpha was 0.940 for general burnout. Responses were made on a 5-point scale ranging from 0 to 4 . The scale labels were then re-coded into 0 , 25, 50, 75, and 100 . Higher scores indicated more burnout. --- Statistical Analysis The demographic characteristics of the participants, along with the surveyed variables, were summarized using descriptive statistics. The chi-square test or t-test was used to compare the differences by occupation. Pearson's correlation was used to analyze the relationships between the continuous variables. Multiple linear regression was used to investigate the relations among work hours, the difficulty in leaving work on time, WFC, and burnout. Among the controlled factors, unmarried workers and white-collar workers were coded as 0; married workers and blue-collar workers were coded as 1. All statistical procedures were performed using SPSS statistics 20 ; a p-value less than 0.05 was considered statistically significant. --- Results To ensure the credibility of the results, we excluded questionnaires with more than 20% of the question items incomplete, leaving a total of 738 questionnaires successfully collected. Table 1 lists the demographic characteristics, WFC, burnout, and other research variables of the participants by occupation. Of the participants, the majority were aged 40-49 or 50-59 , married , and white-collar workers . About two-thirds of the participants perceived their economic status as ordinary ; 77.7% of the participants did not look after any child at home. The comparisons of age, economic status, parental status, work hours, WFC, and burnout by occupation showed significant differences. White-collar employees showed fewer work hours and a lower level of burnout compared to blue-collar employees, but a higher level of WFC. The crude correlations of research variables are listed in Table 2. The responsibility of housework was significantly negatively correlated with work hours and the difficulty in leaving work on time, but not with WFC or burnout. Work hours, the difficulty in leaving work on time, WFC, and burnout were all significantly positively associated with one another. Multiple linear regressions predicting WFC are summarized in Table 3. In Model 1, with demographic factors and family-related factors controlled, the model for work hours predicting WFC was significant ; work hours showed a significantly positive relation with WFC . In Model 2 , with the difficulty in leaving work on time also considered and controlled for in the analysis, the significant effect of work hours on WFC disappeared . However, the difficulty in leaving work on time showed a significant association with WFC . Multiple linear regressions predicting burnout are also summarized in Table 4. In Model 1, with demographic factors and family-related factors controlled, the model for work hours predicting burnout was significant ; work hours showed a significantly positive relation with burnout . In Model 2 , with the difficulty in leaving work on time also considered and controlled for in the analysis, work hours remained positively associated with burnout . In addition, the difficulty in leaving work on time also showed a significantly positive association with burnout . --- Discussion The main purpose of this study was to evaluate the relations of work hours and the difficulty in leaving work on time to both WFC and burnout among female workers in Taiwan. The results showed that in the multiple linear regression analyses, when age, marital status, economic status, occupation, parental status, and the responsibility of housework were all controlled, a higher number of work hours was positively associated with WFC and burnout. When the difficulty in leaving work on time was also considered and controlled for in the analysis, work hours remained significantly positively associated with burnout; however, the significant effect on WFC disappeared. The adverse effects of long working hours on physical and mental health have been evidenced [22][23][24]. A high number of work hours was positively associated with burnout in the present study. This finding is in line with another study conducted in Taiwan; a comparison of high-and low-burnout groups found that long working hours was significantly correlated with burnout in a dose-dependent manner even when physical inactivity was controlled [8]. However, in the present study, the significant association between work hours and WFC disappeared when the difficulty in leaving work on time was considered. Being unable to leave work on time has generally been recognized as a sign of job strain [25]. In modern times, however, many workers have the ability to control their work schedules. When the hazardous effects of long working hours on health are gradual and unobvious, and feelings of WFC decline, workers may choose to spend more time at work unaware of the potential harm. WFC was broadly evidenced to be associated with burnout, depression, and psychological strain [11]. These voluntary extended hours should be a matter of concern. Notably, economic status showed a significant association with both WFC and burnout when the burden of parenting, the responsibility of housework, occupation, and work hours were all considered. Previous research has indicated associations between socioeconomic status and both physical and mental health. A sixteen-year longitudinal study revealed that a change in occupation and income were both related to changes in health. A causal relationship between these variables indicates that initial socioeconomic status affects later changes in morbidity [35]. In addition, a study of 29 countries using European social surveys showed that individual economic conditions were a basic factor contributing to a good state of self-reported health [36]. Regarding mental health, common mental disorders were found to be distributed according to a gradient of economic disadvantage across society [37]. Finally, a systematic review of epidemiological literature found that of the 115 studies reviewed, over 70% reported positive associations between poverty and common mental disorders in low and middle-income countries [38]. Despite these findings, economic status has seldom been discussed in the field of occupational health; this is an obvious oversight. To promote mental health in the workplace, occupational health officials should be concerned about, and further investigate, workers' economic status. The perception of WFC reflects not only time-and strain-based conflict, but also an awareness of the importance of achieving a balance between work life and family life [11]. In the present study, blue-collar female employees reported having significantly longer working hours and higher levels of burnout, along with significantly lower levels of WFC, compared to white-collar female employees. The lower WFC among blue-collar female employees might imply more willingness to put family matters second to work and/or a resignation to destiny. Traditionally in Taiwanese culture, being a "good wife and wise mother" has represented the ideal for womanhood, and is more important than realizing one's personal identity [39]. However, in the modern world, women face previously unknown dilemmas, which can lead to an attempt to shake off the constraints posed by traditional male rights, in asserting their own place in society and affirming their unique existence [40]. Accordingly, more and more women have begun to enroll in higher education and to devote themselves to the labor force [40]. As stated in the Introduction, the female labor force participation rate in Taiwan has increased from about one third in the 1970s to more than one half in the current year [1]. Considering these changes taking place, more research needs to be conducted that addresses the impact of cultural tradition on female identity and self-perception, particularly as it relates to WFC. Further research is also needed to clarify whether the phenomenon in the present study, that is, blue-collar female employees working comparatively more at home and on the job but feeling less WFC, is rooted in the Taiwanese culture or whether other factors pertaining to socioeconomic status are involved. There were some limitations to this study. First, the cross-sectional study design did not allow for the determination of the developmental process and the causal relationships among the research variables. More longitudinal studies are required to explain the mechanism governing the relations among the research variables. Second, the participants took part voluntarily in the present study; thus, self-selection bias could not be ruled out. In addition, all the research variables were obtained via subjective data. Therefore, applying the research results to other populations should be done with caution. Third, the number of blue-collar female employees was small in the present study. At the time of this study, blue-collar female employees in Taiwan occupied about 31% of the labor force [1]. Enlarging the sample of blue-collar employees in future research is recommended. --- Conclusions The present study explored the relations of work hours and the difficulty in leaving work on time to both work-to-family conflict and burnout among female workers. In the regression analyses, when age, marital status, economic status, occupation, parental status, and housework were all controlled, a high number of work hours was positively associated with WFC and burnout. When the difficulty in leaving work on time was also controlled for in the analysis, work hours was still significantly associated with burnout; however, the significant association between work hours and WFC disappeared. Although the adverse effect of long working hours on health has been evidenced, its hazardous effects are gradual and unobvious. Additionally, when feelings of WFC decline, workers may choose to spend more time at work, oblivious to the potential harm they are causing themselves. The deleterious effects of extended hours on employee health should be a concern. In addition, the present study showed that economic status is significantly associated with both WFC and burnout. Nevertheless, the effects of economic status on employees' mental health are seldom examined in the field of occupational health. Further studies regarding this issue are recommended. ---

The present study explores the relations between work hours and the difficulty in leaving work on time to both work-to-family conflict (WFC) and burnout among female workers in Taiwan. A cross-sectional research design and questionnaire were employed to obtain the research data. In total, 738 full-time female workers took part in the study. The results of regression analyses showed that when age, marital status, economic status, occupation, parental status, and housework responsibilities were controlled, more work hours were positively associated with WFC and burnout. When the difficulty in leaving work on time was also considered in the analysis, long working hours were still significantly associated with burnout; however, the significant relation with WFC disappeared. It is surmised that if female employees work overtime voluntarily, the perception of WFC diminishes; nevertheless, the adverse effect of long working hours on health remains unabated. This study concludes that female employees who work overtime on a voluntary basis are at risk of health problems, which should be a focus of concern.

Introduction A disease refers to a disorder that impedes performance or a deviation in the structure and functioning of a system [1]. It is also a harmful impediment to a system's structural norms or function. Commonly associated with physical injury, it occurs in a specified location [2] and often yields specific symptoms that appear [3] to indicate abnormal conditions inherent in such a system [4], [5]. Diseases can morph into contagion, spreading via a medium that includes fomites, oral , direct contact, aerosol, and vector-borne [6]. Its diffusion spread within a society -often yields a regular spread of contagion, epidemic, or pandemic. It can become an epidemic directly impacting society [7]- [9]. Studies today are geared towards modeling propagation tasks on a social graph of connected actors to investigate relations, the structure, and underlying features of interest [10]- [13]. It can exist in 4-forms: hereditary, non-hereditary, deficiency, and infectious [14]. Movement of these actors/agents -plays a critical and significant role in the transformational process [15], [16] of the social graph to help de local disease outbreaks as they morph into epidemic cum pandemics, and vice versa. And thus, it continues to necessitate the inclusion of human migration and interaction into every contagion model -to effectively simulate disease cum epidemic outbreaks and to implement a dependable, dynamic framework as future preventive programs and policies for any contagion [17], [18]. With the unfettered, sporadic movement of nodes , these can portend some issues to include: nodal exposure to diseases , diffusion , and rate of recovery [19]. Our study wishes to address such problems using the movement-interaction-return ensemble that models nodal targeting and exposure to disease/contagion to seek its rate of propagation with exposure to seed-nodes on the social graph as well as compute the expected recovery rate and time of susceptible-infect nodes vis-à-vis the nature of the disease cum contagion. --- Review of Related Literature --- Agent-Based Modeling on Social Networks A social graph is a collection of networked nodes or actors whose interaction with each other ripples formal changes in the nodal observations in relation to their exposure to an idea or innovation. Thus, it advances learning as the innovation diffuses within the structure's nodes [20]. A social graph ripples learning changes propagated across nodal relations as it seeks to explain structural theories of observed patterns and analyze nodal features that eventually morph into global trends [21] via nodal interactions that finally yield a social convergence. These global trends manifest explicitly as nodal ties. Thus, as learning occurs, each node and its relations seek to shape via social interactions -each graph over time to enable the adoption of innovation [22]. A graph 𝐺 = is a structure where each node 𝑖  𝑉, with a corresponding set of links where each 𝑚  𝐸, and has a corresponding assigned weight called the cost or penalty of interaction. Its ties/link, measured using dyads 𝐷 [23], can either be self-looped, singly-linked, or multi-linked. Each graph G is poised with 2-points: to objectify how these nodal structures evolve, and to understudy local features that cascade social processes and specify how we can exploit/explore these local features via nodal interaction [24]. With the society as our case in point, nodal migration and interactions are imperative as they will provide lessons and measures to help combat diseases/contagions as these nodes interact , and ripples within G -a series of corresponding associated costs therein [25]. As local properties morph onto global patterns -modeling migration-interactions can provide crucial knowledge in planning the future states cum scale of an event [26], [27]. Such models become tools to yield insight about the future, with predictions to yield timely insights about the velocity and veracity of a probable event [28]. The reliability of the generated results is best seen as prophesies/forewarnings rather than predictions and is open to questioning as either myths or fictions [29]- [32]. At the crux of nodal interactions is the agent-based model . This is best illustrated with a flock of birds flying as a single system in tight formation. With no leader bird, they gracefully choreograph their movement such that each bird responds to the flight pattern of its immediate neighbor; And results in a highly-nonlinear patterned, hypnotic rhythm [33], [34]. We model such interaction as a sum of local feats represented in 3-rules, namely: separation or collision avoidance in which each bird distances itself from others, alignment for which each bird's direction and velocity are matched by its immediate neighbor, and cohesion for which each bird's preserves a perceived equidistance of both the flock and its immediate neighbor to realize such flight formation with a steady paced, velocity and direction. Each bird is thus, as an actor or agent, modeled with local features whose interaction with the others yields such realistic flight formation or pattern [35]- [40]. Thus, an ABM can yield or be used to represent a dynamic, self-organized, complex, and non-linear framework that cascades local, nodal properties as processes learned by interacting actors/agents in response to a variety of external/internal influences -to yield a global pattern eventually [41]- [43]. ABM's potential focuses on emerging processes to yield a structure that posits a dynamic ensemble shaped via observing nodal interactions, and it tests learning as a social convergence that manipulates the network structure using features such as its nodal stratification, graph topology etc [27], [44]- [47]. --- Diffusion Framework Models For a social network, innovation can diffuse across a graph via seednode actions for tight clusters on a typical susceptible-infect case. The seed-node is a set of infected actors that have adopted an innovation . Other nodes in 𝐺, yet to adopt the innovation, are initialized, and can take any 3-states, namely: susceptible -here, a node can be exposed to an innovation; But has a threshold limit for which aids it to either accept/reject an innovation, infected -here, the node is exposed, and is influenced by its immediate neighbor to accept the innovation having exceeded its threshold limits. Thus, it becomes infected [48], [49] and has the ability to influence other nodes to either accept/reject the innovation and be removed -here, the infected node is placed on treatment, so that in time -the infected node recovers; The same treatment is placed on all other immediate neighbors that are infected till either a stop criterion is reached or no more infected node exists on the social graph and/or network [50], [51]. With this in mind, the susceptible-infect diffusion ensemble can be represented in 2-classes, namely: SI-Susceptible and SI-Remove [52]- [55]: 1. SI-Susceptible: At time t = 0, G inserts into it a set of nodes , such that an infected node 𝑥 has only a chance at any time 𝑡, to be exposed its immediate neighbor node 𝑦. With 𝑦 exposedthe probability that 𝑛 the node 𝑥 convinces node 𝑦 yields 𝑃 𝑥𝑦 -so that if 𝑥 succeeds, then 𝑦 becomes infected at time 𝑡 + 1; Else, 𝑦 may reject now -only to accept later . Also, 𝑦 can reject at time 𝑡 + 1 and then, later, accept at time t+2. This can go on and stop after either 𝑛-steps, or if there exists no node to be exposed. We can also note that a node can be exposed any number of times such that even after such node is treated and has recovered -when exposed, it becomes susceptible again to be infected [56], [57]. 𝐴 𝑑 = 𝑎𝑟𝑔 max 𝑀 𝑑 𝑆 does an adaptive seedset make a choice, And 𝑆 𝑑 is the rate of contagion diffusion in G. Thus, it yields Equation that shows the contagion spread with the randomized seedset to denote the expected propagation and spread over all possible positions with d-innovations placed on G as [39], [63]. 𝑆 ′ 𝑑 = 𝐸 𝑀 𝑑 [ 𝑆] --- Proposed Material and Method --- Data Gathering Nigeria is arguably in Africa, the most strategic and influential nation -in lieu of her being the most populous black nation, her vast natural resources of hydrocarbon vis-à-vis her government's commitment to anti-corruption and to the unity of Africa. The abundance of minerals has continued to foster Nigeria's heavy dependence on her oil, which accounts for over 41% of her Gross Domestic Product and 90% of her export revenues [51], [64]- [66]. The study uses the COVID-19 contagion , and models Delta State as a small-world graph with diffusion time as the lockdown from April 2020 to March 2022. Of the 270-wards in Delta State, we use 27-wards to introduce the seedset as in Table 1. 36% / 80% at 𝑡 > 0 and 𝑡 = 𝑡 -1 respectively --- Problem Formulation The propagation spread size of COVID-19 on society is a function of nodal migration and return, social interaction of participatory nodes and other accompanying epidemiological features. The contagion size is that fraction of the population that remains infected even if and when the contagion has reached a stationary state . A sample contagion size is a seedset introduced into the framework as in Table 1 [67]- [69]. Nodes are represented as migrants and residents via relations to yield the appropriate/requisite ties and tie-strength to 𝐺. Residents yield stronger ties; while, migrants yields weaker ties with nodes on 𝐺. Tie-strengths are measured using dyads 𝑑, and exists in 𝐺 to propagate cluster formations as they morph into communities. Tues are all the pair of interactions between n-nodes with m-ties to form the matrix 𝑇 of 𝑛 × 𝑚 in 𝐺) [70], [71]. Each tie formed helps each node to overcome data issues of retrospective accuracy and acts as data feedback to benefit nodes during migration and return. Thus, we compute tiestrength modeled as a linear combiner to yield Equation -with 𝑁 𝑖 as the structure of 𝐺, 𝑅 𝑖 is all predictive variables, 𝐸𝐼 𝑖 are all shocks in pairs dyadic relations, 𝑒 𝑖 is error term for maximization, and 𝐷 𝑖 is all dyadic pairs. 𝑆 𝑖 = ∝ +𝛽𝑅 𝑖 + 𝛾𝐷 𝑖 + 𝑁 𝑖 + 𝐸𝐼 𝑖 + 𝑒 𝑖 --- Proposed Movement-Interaction-Return Contagion Framework We model the movement-interaction-return contagion framework as a variant of the Markov Model. It models graph 𝐺 as a set of nodes with state transition ties . This variant addresses the fundamental issues raised therein the Markovian process via the use of positional data in the sequences and use of a null transition state to match insert/delete sequences for observed transition [72], [73]. Thus, for the nodal observations, the probability distribution cum state transition for the generated sequences of the task at hand includes [51], [74]- [78]: 1. Targeting with seedset: Given observations m and n, we seek to determine 𝜆 = that best fits the sequence. We train the ensemble to fit the data using the features of interest. HMM training requires no aprior assumptions about the model other than outline parameter 𝑁 and 𝑀, which specifies the model's size. 2. Rate of Infection Diffusion: We compute the probability that the model produces a sequence given that Equation and holds true with = and compute 𝑃. 3. Task-3: We uncover HMM 𝜆 = and observation sequence 𝑂 to determine the most likely sequence of states 𝑋 = that could have produced the sequence. We propose the extended movement-interaction-return framework to consist of three phases, namely: movement, interaction, and return, respectively [79]- [81]: 1. Movement -𝐺 is populated with actors from a variety of geographical locations. Each can migrate across 𝐺 with a probability 𝑃, and are etched with behavioral feats/roles for residents/migrants in a small-world graph to indicate their mobility pattern of choice. 𝐺 uses the parameter 𝑀 𝑗 𝑖 𝑘 to denote nodal movement cum migration such that 𝑅 2 1 denotes a node in cluster-1 migrating to cluster-2; while, 𝑅 1 3 denotes node in cluster-3 migrating to cluster-1; And so on. This governs migration flow to describe the rate of nodal mobility 𝑖 from the sub-𝐺 𝑗 to another 𝑘 as in Equation . 𝑀 𝑗 𝑖 𝑘 = 𝛿 𝑗 𝑖 𝑅 𝑘 𝑗 + 𝛿 𝑘 𝑗 This feature ensures that resident nodes can migrate, and migrant nodes not in their place of residence must be forced to stay at their temporal residence until they are remigrated home. As such, movement holds -both migrant and resident nodes can/may exchange innovation and learn via interaction given in Figure 1a and 1b, respectively. 2. Interaction: With a time-varying SIS in 𝐺, nodes interact with their immediate neighbors. Thus, if and when an infected seedset node 𝑥 is exposed to 𝑦 at 𝑡 + 1, it has just one chance to infect node 𝑦. 𝑃 is the probability rate at which the susceptible node 𝑦 adopts the contagion from its neighbor 𝑥 -given by the infectivity rate 𝜆. Also, a contagion may die, node recovers with treatment, or may continue propagating . The probability the contagion dies after treatment within its host carrier is given by the recovery rate 𝜇 as seen in Figure 2 [82]. 3. Return: Migrants are forced either to stay at their temporary location or return with a probability of𝛾 -1 . This feat accounts for time convergence, where such migrants become destination node. With 𝛾 -1 = 1 -𝐺 recovers to the original MIR form and state . With 𝛾 -1 ≠ 1 -nodes lose data about their residence and become steadily re-distributed across neighbor locations [10] with 𝑡 -1 is as in Figure 3. --- Experimental Procedure Each nodal exposure yields an updated, likely expected maximum number of adopters for the contagion. This implies that the ensemble yields an updated, optimal solution based on re-computed thresholds of exposed cum infected nodes. This update is achieved via the following steps as thus: a. Step-1: We normalize all nodal position as in the algorithm listing 1, within the probability limits and range [0 -1], b. Step-2: We randomly swap each node's position using the roulette swap type to ascertain its rate of adoption/acceptance c. Step-3: With each nodal position reset, we re-computed the new threshold for 𝐺. This process continues till either all nodes are infected or the stop time criterion of 6 weeks is reached. Algorithm end if 13: end for-each 14: Compute the adoption of contagion within the network structure using the linear combiner: 𝑁 𝑖 = 𝑃 𝜃,𝐺 +  0  𝐿 +  1 𝑀𝑒𝑑 𝐿 + ∑ ∑  𝑡 --- Results and Discussion --- Result Findings With each solution found, the ensemble restarts with a randomly selected seedset choice in 𝐺. Nodes with a threshold > 0.5 are chosen as the fit solution. The process stops if/when all nodes are exposed at the time  𝑡 -1, or till a node with a threshold value ≤ 0.49 is reached. Thus, investigating and resolving criteria for targeting -as being the reasons to aid the adoption of an innovation vis-à-vis its propagation of COVID-19 -irrespective of the protocols in place, the results are shown in Table 2 using Equation . The result agrees that the advent of the seedset yields a uniformly distributed acceptance of the COVID-19 contagion in 𝐺. This is seen from the values that with a mean structural distance of 0.09 of population cluster as seedset, yields a threshold spread of 0.67 , with a dyadic interaction +𝐷 𝑖 of 0.93 time convergence and a network structure +𝑁 𝑖 of 0.97 as final adopters. This suggests that a highly clustered 𝐺 will ease propagation time as a higher cluster coefficient further promotes spread ease along each node's personal grapheven with the set protocols and measures to slow the propagation of COVID-19. However, with the migration pattern infused into such a tightly knit, cohesive G as well as accounting for each node's personal graph vis-à-vis the loose network structure introduced with migration -this slows down the rate of infection as seen in Table 4 of final adopters, a 0.95-significance using Equation and . The result shows that even with the seedset, laggards account for 11.4% of 𝐺. It is found to have been skewed considerably from a proportion of non-adopters vis-à-vis the datasets used. Laggards were found not to be infected at time 𝑡 -1 for the study. It was hoped that at this time, all nodes may completely adopt the innovation even with the set protocols cum its adherence. It can be attributed to features that residents cannot abandon their homes just as migrants are quarantined . Some nodes were also found to remain indifferent to the innovation as they neither rejected nor adopted it due to higher threshold. --- Discussion of Findings At time 𝑡  0 of propagation, nodes become exposed to seedset nodes infected with the contagion. Migration ensures that more nodes become exposed and easily adopt/accept an innovation due to shocks . It directly impacted the network's threshold, disposing 𝐺 towards a positive trend ; Although each nodal graph displays a stronger resolve to reject the COVID-19 contagion. The ease with cluster formation, consequently, eased structured learning and interaction as dyadic ties advanced improved nodal retention of data learned in nodal memory in the network's quest for optimal solution. The random exchange of data in a node's personal graph encourages data swap -and, in time, yields an improved nodal disposition for all node-set. The more exposed each node becomes, the more interaction with learning and retaining knowledge that improves each node's disposition and personal network; And in turn, impacts the graph as community-based shocks . This agrees with [20], [46], [83], [84]. The adoption of the MIRensemble has become imperative and crucial as a threshold parameter to study network structures vis-à-vis the lessons learned from the COVID-19 pandemic. A node's adoption time for a specific innovation is proportional to its threshold limits and shocks/influences impacted upon the node by its graph. The advent of seedset rippled in by migration mobility ensured that over 80% of active nodes became infected prior the stop criterion as in Table 4 with the adopters of the innovation as reflected by both the nodal and graph thresholds. This agrees with [85], [86]. Finally, a high threshold value indicates such a node/graph possess high tolerance to reject the contagion, as experienced with the laggard nodes [63], [87], [88]. --- Conclusions Our contributions include thus: we define ties as a dimension in all social-networks 𝐺, we acknowledged and modeled the network structure as a linear function with the probability distribution of nodes in the search domain being considered, and we used the MIR ensemble with mobility pattern as a predictor for both nodal and graph's threshold. Our result extends the realization that help modulate the social features within a graph vis-à-vis filtering actor relations through clusters/cliques, and with recourse to both the properties of the node and the connecting link itself that enables actors/nodes interact with each other. We defined these properties as dimensions in the network structure itself.

Besides the inherent benefits of exchanging information and interactions between nodes on a social graph, they can also become a means for the propagation of knowledge. Social graphs have also become a veritable structure for the spread of disease outbreaks. These and its set of protocols are deployed as measures to curb its widespread effects as it has also left network experts puzzled. The recent lessons from the COVID-19 pandemic continue to reiterate that diseases will always be around. Nodal exposure, adoption/diffusion of disease(s) among interacting nodes vis-a-vis migration of nodes that cause further spread of contagion (concerning COVID-19 and other epidemics) has continued to leave experts bewildered towards rejigging set protocols. We model COVID-19 as a Markovian process with node targeting, propagation and recovery using migration-interaction as a threshold feat on a social graph. The migration-interaction design seeks to provision the graph with minimization and block of targeted diffusion of the contagion using seedset(s) nodes with a susceptible-infect policy. The study results showed that migration and interaction of nodes via the mobility approach have become an imperative factor that must be added when modeling the propagation of contagion or epidemics.

specific and equivalent manner . Therefore, the focus of the current study is on impact of maltreatment multiplicity on children's development. --- Resilience and Child Maltreatment Consistent with the developmental psychopathology framework of multifinality, influences across multiple systems, from genes to society, give rise to divergent trajectories of development for maltreated children . That is, despite the trauma of abuse and neglect, not all maltreated children follow along paths of maladaptation. Instead, children have a remarkable capacity to demonstrate resilient functioning . Resilience refers to the complex and dynamic capacity of individuals to recover or withstand adversities that have the potential to significantly undermine development . Rather than simply referring to an absence of psychopathology, resilience signifies that children have obtained competence in multiple domains of psychological health, or adaptive functioning, despite experiencing adversity. This categorical notion of manifesting resilience leads many researchers to study and characterize resilience using person-centered statistical approaches. Person-centered statistical approaches attempt to characterize similarities and differences among individuals based on the assumption that the population is heterogeneous in terms of the joint distribution of the observable indicator variables . However, modeling the dynamic processes involved in obtaining adaptive functioning in contexts of adversity, such as interactions between risk and protective factors, is generally best-achieved using variable-centered approaches. Variablecentered, as opposed to person-centered, approaches tend to analyze the relations among variables. Hybrid models have grown in popularity because of their ability to incorporate both person-centered and variable-centered approaches to understanding resilience . One type of hybrid model used in this study is referred to as a structural equation mixture model . An SEMM involves testing a structural model with one or more categorical latent variables along with one or more continuous factors. --- Protective and Vulnerability Factors. A key step in resilience research is the identification of protective and vulnerability factors that either enhance or decrease, respectively, the likelihood of healthy development for children faced with hardship. Greater attention to these factors in child maltreatment research will likely contribute to more effective means of identifying children at highest risk of maladaptation as well as improve prevention/intervention strategies . Examples of factors that have been established as protective for maltreated children include a child's connection to safe neighborhoods and quality education as well as a child's selfregulatory and self-esteem capacities . Identified vulnerability factors include low self-efficacy and exposure to high crime neighborhoods . Beyond environmental influences, there has been growing emphasis, in the child maltreatment and resilience literature, on identifying genetic vulnerability and protective factors. By and large, these types of studies test for candidate-variant, gene-by-environment interaction , whereby associations between environmental exposures and psychological phenotypes depend on genotype . Due to extensive non-replication, effect size estimates at odds with hypothesis free/genome-wide approaches, improper statistical techniques, and inconsistent findings, the GxE literature has been highly contentious . Many of the reported candidate genetic moderators of childhood adversity, with roles in multiple biological systems, have been described as conferring individual differences in environmental sensitivity . ES refers broadly to differences in the degree to which individuals perceive, process, and respond to environmental influences. At its core, ES is a concept based on the hypothesis of neurosensitity; namely, more sensitive nervous systems lead to heightened awareness and deeper processing of environmental stimuli . Though still in its infancy as a concept, the notion is that high levels of ES may potentiate the harm inflicted in children by maltreatment. Genetic variants relating to less efficient dopamine functioning or dysregulated hypothalamic-pituitaryadrenal axis activity have been hypothesized to increase ES . Commonly studied genes in this arena the serotonin transporter and the dopamine receptor D4 , which have been reported as moderators of maltreatment outcomes, albeit with varying success in replication . Often limited by the scope of a studies initial genotyping efforts, the vast majority of work on the genetics of psychological well-being in children faced with adversity has been focused on the moderating effects of a dozen or so genetic variants. These studies either examine variants individually or summed as a single polygenic risk score . Often, candidate PRSs involve a count of the number of so-called sensitivity alleles that a given person carries . In general, these studies have reported that the higher the sensitivity allele count the more susceptible individuals are to the effects of maltreatment, in line with the ES concept. Cicchetti and Rogosch , for example, found that maltreated children with multiple sensitivity genetic variants scored lowest on a composite index of adaptive functioning as compared to maltreated children carrying less. At least within the context of candidate GxE research on childhood adversity, most PRSs are unweighted and rely on a priori assumptions regarding which specific alleles of a given genetic variant confer sensitivity and which alleles confer protection. Such approaches are completely reliant on the robustness of previous literature, which has been strongly called into question . Moreover, unweighted PRSs assume that each genetic variant contributes equally to the overall main or interactive effect. When phenotypes and genotypes have been assessed on a large number of people, PRSs have the benefit of being weighted based on genome-wide association studies . These PRSs can be considered a type of fixed-weight composite . However, at least to date, there are no genome-wide GxE studies of child maltreatment to pull data from. These studies do not exist because the immense sample sizes required are currently prohibitive. If the previous literature's robustness is questionable, candidate GxE PRSs may only be able to reasonably be weighted by a study's own sample, otherwise referred to as unknown weights composites . In addition to considering effect size weighting, the coding of genetic alleles in candidate PRSs, in terms of designating which alleles confer sensitivity versus protection, is important. If researchers hypothesize that ES increases as the number of sensitivity variants carried increases, then it is imperative that there be either strong rational based on previous literature for selecting particular variants or a or a flexible statistical method that does not require such a priori assumptions. Unfortunately, there exists inconsistent evidence that any particular allele is robustly associated with any broad sensitivity to the environment phenotype. For example, some studies report the long allele, rather than the traditionally assumed short allele, of the much studied 5-HTTLPR variant is associated with greater reaction to environmental conditions . In an attempt to overcome both issues of weighting and assumptions regarding allelic sensitivity, the current study utilized an unknown weights composite referred to as a formative factor. This approach has never been used in GxE research to date. Unlike a reflective factor from a confirmatory factor analysis, a formative factor is conceptualized as being formed by its indicators, requiring no correlation between indicators. Formative indicators' contribution to a formative factor are weighted as a function of what the formative factor is predicting, such that the indicator weights represent the indirect effect of each indicator on an outcome via the factor . Moreover, formative factors allow for indicator weights to be estimated freely as either positive or negative. This means that the coding designation of sensitivity or protective alleles is not required a priori; only the selection of variants themselves is needed in order to construct a genetic formative factor. --- The Current Study The goal of the current study was to examine if the relation between maltreatment multiplicity and adaptive functioning, in children, depends on variation in candidate variants commonly studied in the ES, GxE literature. First, as a means of quantifying adaptive functioning in maltreated and nonmaltreated children, a latent class analysis was performed on four commonly studied domains of psychological health: prosocial behavior, antisocial behavior, withdrawn behavior, and depression . LCA accounts for measurement error and classification accuracy, does not treat all indicators the same, and avoids relying on researcher cut-offs making it an ideal person-centered modeling technique . Next, 12 genetic variants were selected for use in a polygenic formative factor, based on a review of GxE findings in the maltreatment literature . Finally, the latent class variable representing adaptive functioning was embedded in a variable-centered, structural model wherein class membership was predicted by maltreatment multiplicity, the polygenic formative factor, and their interaction . Our study used an all African-American sample of children. This was done for three primary reasons. First, research with African-American children is severely underrepresented in the current behavioral science literature, especially the genetic literature . Second, genetic analyses have greater statistical power when only one ancestral group is studied at a time because genetic variation covaries with ancestral origin. Finally, the vast majority of the original sample of maltreated and non-maltreated children is African-American. --- Aims. This study has two major aims: --- 1. Describe heterogeneity in multi-domain, adaptive functioning in African-American maltreated and nonmaltreated children of low socioeconomic background. That is, in an exploratory manner, elucidate the number and nature of a finite number of "adaptive functioning" groups of children. --- 2. Predict membership in "adaptive functioning" classes based on maltreatment multiplicity, a polygenic formative factor comprised of 12 ES genetic variants, and the interaction between them . --- Methods --- --- Measures Measures of adaptive functioning.-We utilized multi-informant measures of prosocial behavior, antisocial behavior, withdrawn behavior, and depressive symptomotology. All four adaptive functioning domains, except depression, included multiple measures. Measures within those three respective domains were averaged together and formed into composite parcels . Specifically, facetrepresentative parcels were used . Three confirmatory factor analyses were conducted using the respective indicators for each of the three parcels. Fit indices from all three CFA models indicated good fit to the data, providing support for the cohesion of the indicators for use in parcels. The prosocial, antisocial, and withdrawn parcels along with the measure of depression served as the four indicators in the LCA. Because of the nature of the limited response non-interval scale of these four variables, we discretized them into six-category polytomous variables. See Supplemental Material for more details. --- Peer measure. Peer behavior ratings.: After interacting with their peers during the week of summer camp, children evaluated the characteristics of their camp group peers via a sociometric peer ratings method on the last day of camp . For each peer in the camp group, children were given six behavioral descriptors characterizing different types of social behavior. Children were asked to rate each peer on how characteristic the behavioral descriptor was for that peer on a three-point scale. In the current study, ratings from peers for cooperative behavior, disruptive behavior, shyness, and fighting behavior were used. All ratings from peers on each child for each of the social behavioral descriptors were averaged. --- Counselor measures. Pupil evaluation inventory.: At the end of each camp week the Pupil Evaluation Inventory was completed by camp counselors for children in their respective groups. The PEI consists of 35 items yielding three homogeneous and stable social behavior factors, including likeability, aggression, and withdrawn behavior. Interrater reliabilities based intraclass correlations across the years of camp ranged from 0.72 to 0.85 for likeability, 0.85 to 0.90 for aggression, and 0.72 to 0.84 for withdrawal. Counselor behavior ratings.: Camp counselors completed seven-point ratings of children's behavior each day during three separate, 45-minute, observations during camp . Counselors rated children on 9 items tapping three domains of interpersonal functioning including aggressive behavior, socially withdrawn behavior, and prosocial behavior. Individual counselor assessments for each of the three scales across the three assessment occasions were averaged to generate individual child scores. Interrater reliabilities based on average intraclass correlations among pairs of raters across the years of assessment ranged from 0.68 to 0.80 for prosocial, 0.70 to 0.84 for aggression, and 0.61 to 0.77 for withdrawn behavior. Teacher report form.: Counselor rated behaviors were evaluated at the end of each week by counselors' completion of the Teacher Report Form . The TRF is a validated, reliable, and widely used assessment of behavioral functioning from the perspective of teachers. This measure was used in the present study because camp counselors are able to observe children in a similar manner as teachers. The TRF, contains 118 items rated for frequency, assesses multiple dimensions of child behavioral symptomatology. In the present study, we examined the rule breaking, aggressive problems, and withdrawn subscales. Self-reported measure. Children's Depression Inventory.: The Children's Depression Inventory is a widely used, valid, and reliable, self-report questionnaire to assess depressive behaviors in school-aged children. For each item, children choose from among three option statements, depicting increasing levels of depressive symptoms, in order characterize their experiences in the past 2 weeks. Internal consistency for the total scale has ranged from 0.71 to 0.89. --- Predictors of adaptive functioning latent class variable. --- Maltreatment classification.: The Maltreatment Classification System was used to index maltreatment. The MCS codes all available information from DHS records, making independent determinations of maltreatment experiences rather than relying on case dispositions and official descriptions. For more information on the MCS, see the Supplemental Materials. Maltreatment multiplicity, or the number of maltreatment subtypes experienced, ranging from 0 to 4 was used as the primary maltreatment variable. --- ES genetic variables.: Based on a literature review, 12 genetic variants, thought to confer environmental sensitivity as well as having shown moderation effects on child maltreatment outcomes, were chosen for inclusion in the polygenic formative factor. See Supplementary Material for basis of selecting these variants as well as genotyping procedures. While the formative factor approach does not require the coding of variants in any particular order, we nevertheless designated one allele from each variant was designed as the sensitivity allele. By doing so, the direction and magnitude of the factor loadings will shed some light on the accuracy and/or application of prior research to an all African American sample. These genes and alleles include: 1.) the 7-repeat allele of DRD4-VNTR, 2.) the 'C' allele of DRD4-rs1800955, 3.) the 'val/G' allele of COMT Val 158 Met , 4.) The 'A' allele of DRD2-rs1800497, 5.) the 'del' allele of DRD2-rs1799732, 6.) the 10repeat allele of DAT1-VNTR, 7.) the 'T' allele of DAT1-rs40184, 8.) the 'T' allele of DAT1-rs27072, 9.) the short allele of 5-HTTLPR, 10.) the 'T' allele of CRHR1-rs110402, 11.) the 'G' allele of OXTR-rs53576, and 12.) the 'T' allele of FKBP5-rs1360780. No variants significantly deviated from HWE, except for the DRD4-VNTR variant = 255.28, p = .005). A departure from HWE is not unusual for the DRD4-VNTR nor is it likely to impact the results given strict quality control to prevent genotyping error . This variant was therefore not excluded as an indicator of the polygenic factor . It was unclear which genetic model was most appropriate for each variant based on the extant GxE literature and within the context of an unordered categorical dependent variable. Model comparisons were conducted using each type of coding scheme and ultimately an additive coding model was selected . --- Validation of latent class labeling. California Child Q-Set .: Validation of the LCA 'class labeling' was carried out using a card sorting task called the California Child Q-Set . The CCQ was completed by camp counselors and involves sorting cards, with psychological descriptions written on them, into categories based on how characteristic each card's description is to a given child's observed behavior. The CCQ is widely used for the various psychological scales and criterion developed from it. This measure was not used as a latent class indicator, affording the possibility to independently validate the construct of each class label. --- Data Analytic Approach Latent class analysis.-Using Mplus version 7.4 data analysis software , a LCA was conducted. Class-specific item probabilities and class probabilities are the two primary sets of measurement and structural parameters derived from an LCA, respectively. Item probabilities refer to the probability of endorsing a particular item conditional on class membership. Class probabilities correspond to the distribution of the categorical latent variable, reflecting the proportion of the population predicted to belong in each class . --- Model building process.: Because there were no a priori assumptions about the number or nature of latent classes in this sample, an exploratory process of determining the best-fitting unconditional LCA was undertaken. Following use of best practices outlined by Masyn and Nylund, Asparouhov, and Muthén , a series of LCA models was fit in an iterative fashion. The LCA procedure involves fitting a series of K-class models beginning with a one-class model and stopping at a K-class model that becomes not well-identified Structural equation mixture modeling. (K max The final unconditional LCA model chosen above was be embedded into a larger structural equation mixture model . To do so, an alternative three-step method was utilized . The first step involves selecting the best-fitting unconditional LCA model. In step two, the modal class assignments and classification error rates are saved. Finally, in step three, the structural model is run with a nominal modal class assignment variable used as a single indicator of a latent class variable with the measurement error rates prefixed. A latent class variable is an unordered categorical variable; therefore, the relation between class membership and predictors is parameterized as a multinomial logistic regression. To test for main effects of maltreatment, predictors included maltreatment multiplicity along with sex and age as control variables. To test for GxE, predictors included maltreatment multiplicity as well as the polygenic formative factor, and a polygenic formative factor-bymaltreatment interaction term. The control predictors of age, sex, and any interaction terms with covariates that associated with either maltreatment multiplicity or the polygenic formative factor were also added to complete the final structural model . --- Results --- Selecting an Optimal Latent Class Solution The latent class enumeration results are provided in Table 1. A solution of seven classes was not well-identified, thus consideration was only given for the 1-through 6-class solutions. The LMR-LRT indicated no significant improvement in model fit beyond a 3-class solution. The BLRT was significant for all model comparisons, providing no helpful information for the selection of an optimal class, and was therefore not included in Table 1. The lowest BIC and CAIC values were for the 3-class solution. The most parsimonious K-class model with a high BF ratio, along with the K-class solution with a cmP near 1 was also the 3-class solution. The lowest AWE was for the 2-class solution. The smallest K-class solution with a log-likelihood value lower than that of a 1-class model with all indicators allowed to freely co-vary with all other indicators within its class was the 4-class solution. That is, the 4-class solution was the most parsimonious solution to fit the data better than a fully-saturated mean and variance/covariance model that is an exact fit to the data . Finally, examination of an AIC 'elbow' plot indicated a bend at the 4-class solution. Because of the ambiguity provided by the results of the fit indices, the 3-through 5-class solutions, were further evaluated in terms of classification precession, class separation, and class homogeneity. In all three k-class solutions, the primary driver of class separation appeared to be variation in prosocial and antisocial behavior. --- Well-adjusted class The largest model-estimated class from the 4-class solution was given the label of 'well-adjusted' and can be visualized in Figure 1A. This class is characterized by high probabilities of exhibiting high levels of prosocial behavior . The well-adjusted class is also characterized by a high probability of low antisocial behavior. Finally, children in this class have high probabilities of endorsing low levels of depression and low levels of withdrawn behavior. This class was given the label of 'well-adjusted' because the profile of competence characterized by this class is similar to profiles considered developmentally adaptive and predictive of positive life-success . Since all children in the sample were from high-risk contexts , children in this class may be considered to be demonstrating resilient functioning. --- Socially-dominant class The next largest model-estimated class was labeled 'socially-dominant' and can be visualized in Figure 1B. This class had the lowest levels of withdrawn behavior compared to all other classes. This class is characterized by medium levels of prosocial behavior and medium to medium-high levels of antisocial behavior. Finally, this class had a high probability of exhibiting low levels of depression. This class was labeled 'socially-dominant' because the profile it characterizes matches the literature-defined expression of social dominance, including high social presence as well as use of both cooperation and aggression . Social-dominance refers a pattern of resource acquisition and social control whereby both cooperation and coercion are used. Socially-dominant children are often admired and socially-influential though not necessarily without the use of antisocial behaviors such as bullying to gain such social centrality . --- Externalizing class The third largest class that emerged from the 4-class LCA was termed the 'externalizing class' and is plotted in Figure 1C. This class's most prominent feature was the high probability of exhibiting extremely low levels of prosocial behavior and high probability of high levels of antisocial behavior. Moreover, this class was characterized by relatively low withdrawn behavior. The somewhat mixed endorsement probabilities for depression, in this class, is perhaps to be expected because some children exhibit impulsivity and even agitation as the result of depressive feelings . The relatively low levels of withdrawn behavior in this class is consistent with the notion that children characterized by externalizing behaviors are not generally inhibited or reserved, socially. However, this class still has an estimated 21% of children exhibiting withdrawn behavior greater than .5 SD above the sample mean. This is also not necessarily an unexpected finding nor does it negate the rationale for labeling this class as externalizing. In fact, a subset of children are both aggressive and withdrawn; in these cases antisocial behavior is thought to contribute to social rejection and victimization which may in turn contribute to lonely and reserved behaviors . In summary, based on the profile of category endorsement probabilities and consistency with definitions in the literature, this class is considered to represent children who exhibit primarily externalizing symptoms. --- Internalizing class The smallest estimated class is considered the 'internalizing class' and is plotted in Figure 1D. This class is characterized by low levels of antisocial behaviors and medium levels of prosocial behavior. This class had relatively high levels of withdrawn behavior. Finally, category endorsement probabilities for depression were mixed. On one hand, this class had the highest probability of endorsing the highest category of depressed behavior out of all the classes. Moreover, individuals in this class are estimated to be more likely to have depression scores above the mean than below the mean. Nevertheless, 25% of individuals in this class are expected to have depression scores below .5 SD below the mean. These mixed endorsement probabilities for difference levels of depression suggest poor item homogeneity. Though, because of low base rates, uncovering a class of children homogeneous for very high levels of depression is unlikely, even in a class characterized by high withdrawn and low antisocial behavior. --- Construct validity of latent class labels The ego-resiliency and social competence q-sorts of the CCQ were used to validate the welladjusted class. To validate the externalizing, internalizing, and socially-dominant classes, the internalizing q-sort, externalizing q-sort, and social dominance q-scale, respectively were utilized . Each CCQ measure associated positively with membership in the respective class being validated when compared to membership in each other class. These results suggest good construct validity and provide a degree of assurance in the labels used for each class. --- Structural Equation Mixture Modeling Results Global maltreatment multiplicity results.-Because the latent class variable has three unordered categories, regression results are based on a multinomial logistic regression, in which simultaneous pairs of logistic regressions are tested . To test for global effects, Wald statistics were estimated. Maltreatment multiplicity was significantly associated with latent class membership . To visualize this global effect, an overall probability plot is depicted in Figure 2. As the number of maltreatment subtypes increases the probability of being in the externalizing class increases and the probability of being in the well-adjusted class decreases. There are slight declines in the probability of being in both the socially-dominant and internalizing classes as maltreatment increases. Selecting a formative factor model.-The 'additive' model was ultimately selected for use in the final SEMM . Initially, each genetic variant was scored in terms of the number of putative sensitivity alleles. However, not all of the genetic variable indicator weights loaded onto the factor model in the same direction. That is, not all alleles contributed to the overall GxE effect in the same manner. Some variants, assumed to have a vulnerability-like effect exhibited a protective effect and vice versa . To simplify the interpretation of the formative factor, variants were reverse-coded in the final SEMM so that all variants contributed positively to the factor. This did not change the size of the Wald statistic for the global GxE effect. --- Multinomial logistic regression Final structural equation mixture model with control variables. -After testing all covariate interaction effects, there were only significant associations between the polygenic factor and age and sex and maltreatment . The association between polygenic factor and age is unusual, and may be spurious. Nevertheless, this association may still bias the GxE effects. Because of these associations, it was necessary to add sex-by-factor and age-by-maltreatment interaction terms as control variables, in addition to sex and age as main effects . The final model regressed the latent class variable onto maltreatment multiplicity, the polygenic factor, the interaction between maltreatment and the polygenic factor , age, the interaction between age and maltreatment, sex, and the interaction between sex and the polygenic factor. --- Global GxE results.: A Wald test for a global GxE effect was significant controlling for all other variables . That is, the effect of maltreatment on class membership depends on the level of genetic variation. There was no significant association between the polygenic factor and maltreatment, ruling out gene-environment correlation . The results of the polygenic factor indicator weights are presented in Supplemental Table 2. All but one genetic variant loaded significantly to the formative factor. Five genetic variants loaded negatively onto the factor, meaning for these variants, the alleles assumed to confer 'sensitivity' in fact contributed protection. These variants included 1.) the 7-repeat allele of DRD4, 2.) The 'del' allele of DRD2-rs1799732, 3.) the short allele of 5-HTTLPR, 4.) the 'T' allele of CRHR1-rs110402, and 5.) the 'T' allele of FKBP5-rs1360780. With genetic variants loading in both positive and negative directions, factor scores can be difficult to interpret, and therefore we reverse coded those variants. As can be seen from the well-adjusted GxE plot, higher factor scores decrease the probability of class membership as maltreatment multiplicity increases. Based on these vulnerability relations we considered higher factors scores as potentially representing higher levels of ES genetic load, bearing in mind that the reverse-coded five variants contributed to this vulnerability effect in an unexpected manner. --- Multinomial logistic regression results.: To further interrogate the global GxE effect, the results of the six pairwise logistic regressions are presented in the Supplemental Table 3. Only two significant pairwise GxE effects emerged, controlling for all other variables. One GxE effect corresponds to the comparison between the well-adjusted class and externalizing class. Specifically, the effect of an increasing maltreatment multiplicity on the odds of being in the externalizing class versus the well-adjusted class increases as ES genetic load increases . The other GxE effect corresponds to the comparison between the externalizing and socially-dominant classes. Specifically, the effect of an increasing maltreatment multiplicity on the odds of being in the externalizing class versus the socially-dominant class increases as ES genetic load increases class . Only one pairwise comparison had a significant maltreatment main effect that was not in the context of a GxE. Maltreated children were slightly more likely to be in the socially-dominant class versus the well-adjusted class . --- Sensitivity analyses.: A variety of sensitivity analyses were conducted to insure the robustness of this model. See Supplementary Materials for more details. In summary, our sensitivity analyses tested and confirmed four assumptions: 1.) maltreatment multiplicity could be treated as a continuous variable, 2.) there was no differential item functioning with respect to maltreatment status, 3.) the formative factor results were not dependent on which genetic variant was used as the anchor, 4.) maltreatment multiplicity was not associated with study cohort, and finally that an unweighted polygenic index also demonstrated GxE effects. --- Discussion --- Study Overview This study had two primary aims. The first was to characterize adaptive functioning in maltreated and nonmaltreated, African-American children. The second aim was to predict variation in adaptive functioning based on maltreatment multiplicity, environmental sensitivity genetic variation, and their interaction . Child maltreatment was highly associated with adaptive functioning, in particular increasing the odds of membership in maladapted classes such as the externalizing group. Moreover, an interaction between child maltreatment and a polygenic formative factor comprised of putative sensitivity variants significantly predicted latent class membership. This study was the first of its kind to combine latent class analysis with the use of a formative factor to test for GxE. --- Comment on the Latent Class Analysis A 4-class solution was chosen as the best overall unconditional latent class model. The four classes were labeled as 'well-adjusted', 'externalizing', 'internalizing', and 'sociallydominant'. Approximately 31% of maltreated children were modally assigned to the welladjusted class and would therefore be considered resilient. These proportions closely resemble those from similar resilience studies on child maltreatment . In general, profiles of externalizing and internalizing behaviors are considered maladaptive for children's development. For example, children with high levels of these broadband behaviors tend to have more difficulty maintaining friendships, are at heighted risk for abusing substances in adolescence and adulthood, tend to display difficulties in school performance, and tend to be victimized more by their peers . In order to climb the social ladder, enhance likability, and control resources, some children engage in highly competitive dominance strategies marked by both cooperative as well as coercive behaviors. Such profiles of social dominance, as seen in this study, can indeed increase the odds of obtaining social influence and resource control especially in the early years of life . As children age, however, patterns of behavior that are predominately prosocial in nature are more consistently linked with positive peer preferences. Competitive social behaviors in middle childhood, even those that include the use of cooperative strategies, that are marked by hostility and aggression can lead to peer rejection and victimization . Comparing the results of this measurement model with other studies is difficult. For one, a LCA with similar indicators of adaptive functioning has not been used with maltreatment data to our knowledge. Moreover, the majority of mixture modeling techniques used in resilience research employ growth mixture modeling as opposed to cross sectional LCA . Yates and Grey conducted on LCA on a similar sample of high-risk children using indicators of adaptive functioning. A four-class solution was extracted with subgroups labeled as resilient, maladapted, internally resilient, and externally resilient. While some competence indicators used by Yates and Grey were similar to those used in present study , other indicators were not , making a direct comparison of models problematic. Nevertheless, the profiles of behavior observed in this study are commonly reported in both typical and high-risk child populations . --- Maltreatment Multiplicity and GxE Predictors of Latent Class Membership Beyond simply describing heterogeneity in adaptive functioning, via an LCA, this study aimed to understand how maltreatment experiences and ES genetic variation relate to adaptive functioning. The association between maltreatment multiplicity and adaptive functioning class membership was first tested outside the context of a GxE. In terms of overall probabilities, as maltreatment multiplicity increased children became more likely to exhibit profiles consistent with externalizing behaviors and less likely to exhibit profiles of well-adjustment. The association between abusive histories and behaviors such as aggression, impulsivity, and delinquency are some of the most robust findings in all of psychology . The chaotic, hostile, and dysfunctional parent-child relationships evident in cases of maltreatment can disrupt the healthy development of children's ability to adaptively regulate emotions and actions. These regulatory deficits compounded by problems in social information processing, known to result from maltreatment, greatly increases children's antisocial tendencies . Such antisocial behaviors, as characterized in the externalizing class in this study, are associated with negative outcomes including risk for substance use and academic problems . While maltreated children had a significantly higher likelihood of being in the sociallydominant class than the well-adjusted class, this effect was small and reflected the rather slight increase in the overall probability of socially-dominance class membership as a function of maltreatment multiplicity. These results are largely in line with the findings from Teisl et al. . That research group also preformed mixture modeling, identifying three group of children characterized by non-dominant behaviors, primarily coercive dominant behaviors, and primarily competent/cooperative dominant strategies. Maltreated children, regardless of the type of maltreatment, were more likely to be in the primarily coercive dominant and non-dominant class as compared to the competent class . It is unclear why Teisl et al. found larger effects relating to the effects of abuse on maladaptive social dominance behaviors. One explanation was that we only identified one bistrategic socially-dominant class rather than sub-classes characterized by primarily coercive or competent dominating strategies. Had we identified these sub-classes, the maltreatment associations may have been stronger. That is, the small maltreatment associations with social-dominance in our study may be muddied by the presence of distinct dominance groups within the bistrategic class. Moreover, it is possible that the inclusion of measures of internalizing behaviors may have created difficulty in extracting more fine-grained profiles of social dominance. In any case, in our sample maltreated children were more likely to be characterized by dominating behaviors. Social learning perspectives have suggested that exposure to adult models of instrumental aggression and dominance common to abusive parenting may lead children to over emphasize the need to use socially-dominant behaviors . The lack of findings suggesting increased odds of being in the internalizing class as a function of maltreatment multiplicity is inconsistent with a large body of literature suggesting otherwise . While maltreatment multiplicity was associated directly with the individual, ordinal measure of depression there was no association with the individual measure of withdrawn behavior. These somewhat discrepant findings could explain the overall lack of association with class membership. Moreover, the estimated class size was relatively small for the internalizing class . Therefore, low power in this study could have contributed to type II error. Finally, some children with otherwise internalizing struggles may exhibit irritability and even aggression, making a distinction between purely internalizing versus externalizing behaviors somewhat difficult to make . Indeed, there was some non-negligible probability of exhibiting moderate levels of withdrawn and depression behavior in the externalizing class. A formative factor comprised of 12 genetic variants, shown to exhibit GxE effects in previous studies, was constructed and included as a moderator of the association between maltreatment multiplicity and adaptive functioning class membership. There was an overall significant GxE effect, such that as genetic load increased maltreated children became increasingly more likely to be members in the externalizing class and less likely to be in the well-adjusted or socially-dominant classes. An advantage of using a formative factor to construct polygenic indices is that the contribution of each variant to the factor can load either in a negative or positive direction. Interestingly, five of these variants loaded onto the formative factor negatively, thereby exhibiting protective rather than the expected sensitivity effects. These findings highlight the complexity of G-E interplay as well as further add to the mixed-findings commonly reported in the candidate GxE research community. It is not uncommon for studies to report discrepant findings for these particular genetic variants. A number of reports, for example, have found the short allele as opposed to the long allele of 5-HTTLPR confers protective effects in contexts of abuse . Contradictory vulnerability/protection effects with regards to FKBP5-rs1360780 and CRHR1-rs110402 have also been reported .What is clear from our study is that all variants appear to have meaningful moderation impacts. These results corroborate the relative importance of these genetic variants in differentially predicting developmental outcomes in contexts of adversity. Moreover, these results add to a growing number of studies demonstrating polygenic moderation of child maltreatment outcomes . This study built upon earlier work by Cicchetti and Rogosch sharing some similarities and differences. In general, Cicchetti and Rogosch's findings indicated that ES gene variation was differentiating, in terms of adaptive functioning, for both non-maltreated children and maltreated children more in line with differential susceptibility theory . However, by 'eye-balling' the plots in Figure 3, our results appear to display interactions more consistent with diathesis stress . There are statistical tools to decipher the person-by-environment interaction effects of vantage sensitivity, DST, and DS . These tools are most effective when a study's environmental range stretches from positive to negative. The current study has a restricted environmental range with only children from low-income backgrounds sampled. Thus, these tools were not employed. Moreover, there is no clear way of identifying interaction patterns such as those listed when the outcome variable is unordered and categorical. One potential reason for why our results are slightly different than Cicchetti and Rogosch is that they used a continuous variable of adaptive functioning and did not employ a weighted composite for their polygenic index. In summary, we replicate and extend very well-known findings in the child maltreatment literature, namely that child maltreatment is strongly associated with negative outcomes and that common genetic variation does not play a major role in differentiating children in terms of adaptive functioning. We demonstrate that candidate GxE polygenic risk scores can be sample weighted and that a priori assumptions about allelic risk/protection is not required. While we report significant GxE findings, they should be treated with great caution and replication attempts should be made. The effects were small and roughly half of the genetic variants had the opposite GxE trend as commonly reported in previous work in the field of childhood adversity. With any study of parent behavior-child behavior associations, the directionality of causation can be difficult to infer. Because this study did not employ a twin or adoption design, nor utilize longitudinal data, definitive conclusions regarding the causality of the impacts of parental abuse/neglect cannot be made. Although statistical GxE interactions were detected, these interactions say little about how the interactions operate biologically at a mechanistic level. Furthermore, not all unobserved contextual factors common to both caregiver and child were controlled for, which can increase Type 1 errors though, in practice adding all such factors in a model is extremely difficult. Finally, not all commonly utilized indicators of adaptive functioning were measured, such as academic success . This study had a number of notable strengths. First, maltreatment was measured objectively and prospectively. Second, this study examined adaptive functioning in four major domains of competence based on measures collected by multiple informants via an LCA. Third, rather than focusing on a single candidate gene-variant, 12 variants were examined across 8 genes collectively via formative factor. The formative factor not only provides a weighted composite, but also allows variants to load either negatively or positively. Because of this, interaction effects were not dependent on the a priori assumptions made about plasticity effects. To the best of our knowledge, this is the first time a formative factor has been used to weight genetic effects; it is also the first time a formative factor has been used in an interaction and the first time that a formative factor has predicted a latent class variable. Finally, GxE research is fraught with underpowered studies. This study used a relatively large, ancestrally-homogeneous sample. In accordance with recommendations made by Keller , covariate interaction terms were added, ensuring proper use of control variables. --- Concluding remarks Given the amount of novel statistical techniques used in this study, caution is warranted regarding the GxE effects. GxE studies are notorious for non-replication . Despite proper use of control variables and large sample sizes, definitive conclusions regarding the impact of these 12 ES gene-variants on maltreatment multifinality awaits repeated replication. Researchers are encouraged to test the utility of formative factors when conducting GxE research and/or mixture modeling research. In no way do these results suggest that any child is 'immune' to the detrimental effects of maltreatment. Child abuse affects all children regardless of genotype; every effort should be made to prevent maltreatment from occurring. If anything, these results suggest that common variation in just a few genes has a small impact on explaining different behaviors observed in maltreated children of African-American ancestry. At any point in a child's life, environmental protective factors such as supportive caregivers, strong peer groups, or an influential teacher can dramatically promote resilient functioning. Child maltreatment is one of the most detrimental environmental exposures that any individual can experience; continued efforts to study psychological health outcomes of maltreated children will likely help develop more effective prevention and treatment tools. --- Profiles of Adaptive Functioning Note. The z-score range cut-offs for each category of the antisocial, withdrawn, and depression variables is Cat1= < -.5 SD; Cat2= >-.5 to 0 SD; Cat3= >0 to .5 SD; Cat4= >.5 to 1 SD; Cat5= >1 to 1.5 SD; Cat6 = >1.5 SD. The z-score range cut-offs for each category of prosocial variable is Cat1= < -1.0 SD; Cat2= >-1.0 to -.5 SD; Cat3= >-.5 to 0 SD; Cat4= >0 to .5 SD; Cat5= >.5 to 1 SD; Cat6 = >1. Controlling for sex and age. Fit indices for LCA of adaptive functioning --- Supplementary Material Refer to Web version on PubMed Central for supplementary material. ---

This study used a structural equation mixture model to examine associations between child maltreatment, polygenic risk, and indices of adaptive functioning. Children aged 6-to 13-years (N = 1004), half maltreated, half nonmaltreated, were recruited to attend a research day camp. Multiinformant indicators of prosocial behavior, antisocial behavior, withdrawn behavior, and depression were collected and used in a latent class analysis (LCA). Four classes emerged, characterizing 'well-adjusted', 'externalizing', 'internalizing', and 'socially-dominant' groups. Twelve genetic-variants, previously reported in the GxE literature, were modeled as one weighted polygenic risk score. Large main effects between maltreatment and adaptive functioning were observed (Wald=35.3, df=3, p<0.0001), along with evidence of a small GxE effect (Wald=13.5, df=3, p=0.004), adjusting for sex, age, and covariate interaction effects. In the year 2015, Child Protective Services in the United States received child maltreatment referrals involving approximately 7.2 million children (U.S DHHS, 2017). Children with a history of abuse or neglect are often deprived of the intellectual stimulation, guaranteed safety, nutrition, and emotional support necessary for healthy development. Experiences of maltreatment place children at heighted risk of developing diverse forms of psychopathology, as well difficulties in academics, interpersonal relationships, and cognitive functioning (Cicchetti, 2016). The specific effects of particular subtypes of maltreatment are largely undetermined and extremely difficult to study as most maltreated children experience multiple subtypes, or maltreatment multiplicity (Cicchetti & Rogosch, 2012). Several studies demonstrate that with every additional form of caregiver victimization, maladaptive outcomes across multiple psychological domains increase in severity (Cicchetti & Rogosch, 2012;Edwards, Probst, Rodenhizer-Stämpfli, Gidycz, & Tansill, 2014). There is some evidence of subtype specificity such as the association between sexual abuse and substance use in women, as well the role of physical abuse in the development of antisocial behaviors (

Introduction: Contributing to Fourth Age Studies Through Literary Gerontology In 1926, the Irish poet William Butler Yeats , in his early sixties, proclaimed "That is no country for old men. The young / . . ., / . . . all neglect / Monuments of ageing intellect" . These lines, which are a reflection of Yeats's life-long artistic and existential preoccupation with aging, articulate what he regarded as the nearly irreconcilable differences between the world of the young, deictically distant from the persona as suggested by the opening "That" in the poem, and the world of the old, which was relegated to the margins of the dominant reign of the young. However, nearly a century after Yeats's bleak pronouncement, it can conclusively be claimed that "that" dominance of the world of the young is-at least in numerical terms-no more, for the aging of the global population is here to stay. As the 2002 UN report World Population Ageing 1950-2050 observed, "by 1998 the historic reversal in relative proportions of young and old had already taken place in the more developed regions," The Gerontologist cite as: Gerontologist, 2018, Vol. 00, No. 00, 1-8 doi:10.1093/geront/gny035 Advance Access publication April 21, 2018 and, as the report ominously contended, "the young populations of the past are unlikely to occur again" . For the last six decades population aging has been a source of particular and increasing concern in the political arena at a global level. This time frame is often established on the basis of the United Nations' first official report on population aging and its social and economic consequences, . The aging of the global population is deemed to be one of the most dramatic societal changes of the twenty-first century and an irreversible trend. One of the most significant features of this global phenomenon is the rapid aging of the aging population, which was already remarked upon in the 2002 UN report and expanded in the World Population Ageing 2015 UN report. It is estimated that by 2050 the oldest old will have more than tripled in number since 2015 ; whereas at the turn of the twenty-first century this segment of the population represented one tenth of older people , by 2050 it is estimated that it will stand for one fifth . In the fields of gerontology and age studies, this rapid aging of the aging population has gained increasing critical attention and has led to the revision of the manner in which old age has been analyzed in what is, in retrospect, perceived as an overly generalizing approach to this increasingly longer period of later life. Two of the key actors in this revisionary approach to the study of old age, Paul B. Baltes and Jacqui Smith, have observed the need to distinguish between a third age and a fourth age in order to reach a better understanding of the development of the aging population . Their distinction is based on the concepts of young-old and old-old, which were first introduced by psychologist Bernice L. Neugarten and historian Peter Laslett . Significantly, and in line with the development of aging at the time in which these scholars produced their research, their work focused on the analysis of the third age , which was characterized by a positive approach to the possibilities of youngold age. This was not only in terms of improved individual quality of life, but also because of the potential for the young-old to become, as Neugarten contended, "agents of social change in creating an age-irrelevant society and in thus improving the relations between age groups" . Baltes and Smith's ground-breaking work in identifying the "multiple ages of old age" and the peculiarities of the young-old also implicitly contributed to a polarized view of the third and the fourth age, in which the latter was defined as "a period of decrepitude that particularly affected those who lived beyond their mid-80s" . Baltes and Smith inherited and perpetuated this polarized perception of the third versus the fourth age, according to which "[t]he good news about aging is the news of the third age" ; what lies beyond young-old age is a barren valley marked, as they conclude, by "a high prevalence of [physical and psychological] dysfunction and reduced potential for enhancement of function" . More recent work on the fourth age, however, has focused on the analysis of ways in which a more nuanced view of very old age can be produced, which acknowledges its distinctiveness as well as the diversity in the manner in which this old-old age is experienced. Social theorists Paul Higgs and Chris Gilleard's work on the fourth age explores possibilities to subvert the negative view of aging that is often associated with very old age. They do so by defining the fourth age as a "social imaginary," namely "a product less of nature than of the 'social mind," which is often depicted as negative, "that old, 'real' old age which we have always feared" . Thus, whereas earlier scholars based their distinction between the third and the fourth age on statistics and biological factors, thus allowing for the identification of an age bracket at which the transition into the fourth age was said to occur, Higgs and Gilleard contend that the fourth age is socially constructed as a process of "othering" old-old age which enables the preservation of the third age as an image of "active, healthy, productive or successful aging" . In order to produce this imaginary of the successful aging of the third age anything that is feared, hideous and abject about aging is displaced into the area of willing unknowability relating to physical, psychological, and social decline of old age. This becomes the construct of the fourth age, namely "a collectively imagined terminal destination in life-a location stripped of the social and cultural capital of later life which allows for the articulation of choice, autonomy, self-expression, and pleasure" . The main way to combat the fear of the unknown "'deep', 'real' or 'frail' old age" is by producing research that casts light on the reality and specificity of the fourth age so as to offer a more balanced view of the diverse experiences of very old age. In literary gerontology, the aim to counter negative cultural constructs of aging and to expose the adverse effects of such images on individual perceptions of aging as represented in literature has inspired many of the seminal studies in the field. As a number of scholars have acknowledged, literary gerontology may at times admittedly have been spurred by a positivist approach to the potentialities of aging . In this sense, in Aged by Culture , cultural critic Margareth Morganroth Gullette self-critically acknowledges that her seminal study Safe at Last in the Middle Years had been guided by what she calls her "tic-a cultural tropism-of looking primarily for signs of progress " . Gullette concludes that "[a]lthough the politics of optimism and resilience is appropriate when we focus on resisting age ideology, at this stage of our examination of culture and the economy we must be nuanced and precautionary " . This need for nuance, which is essential in order to foreground the complexities of the aging experience, has guided the work of literary gerontologists as well as recent developments in this field. In Figuring Age , for example, Kathleen Woodward notes the need to move away from essentialist discourses that disregard the diversity of the aging experience in women , and concludes her introduction to this collection of essays remarking on the need for greater diversity in the analysis of the focus theme of her study, namely women, bodies and generations . Besides, the recent engagement of literary gerontologists with illness and disability studies purportedly contributes not only to complicating facile associations of illness and disability with undesirable old age, but it also furthers the realization that aging, particularly in relation to very old age, is necessarily an experience of gains and losses. This is in line, not only with Erik Erikson's principle of dynamic Balance of Opposites regarding individual psychosocial development throughout the life course , but also with philosopher Jan Baars's "dialectic of loss and gain" . According to Baars, a binary understanding of the aging experience is the result of "fears caused by the insecurities of future life in which an uncertain future of aging is not looked in the eye" . In his probing into what he terms "the dialectic of loss and gain" , Baars calls for the need to understand that what are popularly perceived as gains and losses of aging are, in fact, interrelated processes, and that the negative aspects should not be "denied the dignity and careful attention they deserve [as] aspects [that] are inherent in human life" . One of the factors that require complexity and nuance of analysis of the oldest old is precisely the diversity of experience that is particular to fourth agers . As Poon and Cohen-Mansfield observe in their study of well-being in the oldest old, "the large amount of individual variability within the cohort . . . makes it difficult to reach generalizations for the group," which, according to these authors, may also account for "the lack of exploration into the well-being of individuals in the fourth age" . This lack of sufficient analysis of the fourth age suggests the need to approach the study of the oldest old in a manner that is characterized by the importance of attending to their individualized experience through the use of longitudinal, qualitative studies. It is in this sense that the use of literary narratives is particularly pertinent, not only because they can provide an insight into imagined experiences of aging in very old age, but also because of their transformative potential. As Wyatt-Brown , literature and its scholarly study through literary gerontology help "comprehend the varieties of aging experience in our time," particularly as " [n] arratives have the capacity to create a picture of aging, one that most readers can easily understand and appreciate" . Renowned literary gerontologist Barbara Frey Waxman goes even further when articulating her understanding of the role of literature and literary criticism in relation to aging. She contends that "[l]iterary texts not only entertain, not only reflect the society in which they are produced, but also are capable of changing people's attitudes and politics, of influencing the world," while literary critics "may be able to capture a wider audience and have more of an impact on how people read-and how they afterward might behave, thereby revealing how texts work to initiate cultural change" . It is in line with this understanding of the potential of literature and literary gerontology to effect cultural changes that the present analysis of Jennifer Johnston's two literary texts is situated. This view regarding the potential cultural benefits to be obtained through literary gerontology has also inspired existing research. Thus, Oró-Piqueras and Goldman are relevant examples of the manner in which literary gerontology contributes to the representation of the complexities of the aging experience. Goldman's study is particularly relevant to the present work as a recent example of critical engagement with Higgs and Gilleard's analysis of the fourth age, though from the perspective of the interrelationship between literary gerontology and illness and disability studies. This article thus contends that the study of the oldest old characters in Irish writer Jennifer Johnston's Truth or Fiction and Naming the Stars provides an insight into the distinctive and individualized experience of the very old, which can also contribute to the type of cultural change that, as Higgs and Gilleard claim, is required to reimagine the social imaginary of the fourth age. Truth or Fiction: An Oldest Old Character's Regard of "Extreme Old Age" as "Not to Be Recommended" Johnston's Truth or Fiction starts with a first-person, middle-aged English female narrator, Caroline Wallace, recounting her frustrated expectations for a conventional life-"I would have liked to have had a couple of babies, a dog and a cat" -which she regards as unrealizable at the age of 45. Having set the stage for the conflict to come, the narrative moves to the third-person at the point in which Caroline, a literary journalist, is commissioned to write a feature piece on Desmond Fitzmaurice, a nonagenarian Irish dramatist living in Dublin who has been ignored by the public for years, if not decades. This task, for which Caroline has to leave London in order to visit the writer over the course of a couple of days, coincides with a crisis point in Caroline's life. This crisis erupts when Herbert, a writer by trade and her partner of ten years, unexpectedly proposes to her one morning when stepping out of the bath, because that would be his "prize" after completing his latest book. This marriage proposal, as blasé and untimely as it is prosaic, enrages Caroline, who departs for Dublin undecided as to what her response will be. From this point on, the third-person narrative pitches Caroline's midlife critical point against Desmond's aging experience, which maintains the narrative focus for the remainder of the novel. By right of age, Desmond unquestionably belongs to the oldest old, the most rapidly growing group in Ireland . However, his adscription to this group is not merely based on his biological age, but rather on the manner in which he experiences his own very old age, as it is socioculturally defined. Thus, from his first encounter with Caroline, Desmond displays some crystalline insight into the manner in which his old age is construed from the perspective of younger eyes, a process which disempowers fourth agers by having their experience recounted, as Higgs and Gilleard note, as "third person narratives" . Thus, the choice of narrative voice in this literary text foregrounds the process of othering implicit in common representations of the fourth age as characterized by frailty, the death of the social and the loss of agency, in short, all those elements that are imagined from the perspective of younger generations as a state to be feared, "a source of contamination, disgust and otherness, a 'dirty' old age threatening all who come close to it" . Desmond's accurate understanding of this othering discourse is what enables him to adroitly discern the cause of Caroline's awkwardness during their first meeting, which leads him to enquire: "Are you frightened of me?," adding that "[y]oung people are sometimes frightened of old people. It's not necessary, you know. I am not a frightening man. By no means" . The fear that Desmond knows to be associated with what he calls his "extreme old age" has its roots in the collective imaginary that has pushed the abject aspects of aging into the recesses of a collective unconscious which Higgs and Gilleard have likened to a black hole. As these social theorists contend, the gravitational pull of this metaphorical black hole generates the "event horizon," namely "a point where light disappears completely" . As they observe, "the fear of the fourth age is a fear of passing beyond any possibility of agency, human intimacy or social exchange of becoming lost in the death of the social, a hyper-reality from which there is no reality to return to" . In the case of Desmond's fourth age, he is aware of the manner in which advanced old age is associated with a "social death" that renders him invisible, at best, abject, most often than not. The definition of social death has been traced back to French sociologist Robert Hertz's use of the term in an essay written in 1907. In this essay, Hertz refers to the fact that death does not only involve the termination of biological life, but also of the individual's social presence, which would often follow biological death. However, the increase in life expectancy and the aging of the aging population have implied the association of social death with very old age, thus preceding biological demise . According to Sweeting and Gilhooly , this association of very old age with social death is explained by the fact that "in Western industrial societies great value has been placed on the productive contribution of individuals" . In the case of Desmond, his lack of creative output as a writer in later years has led him to this type of social death, as suggested by Caroline's Literary Editor, when she remarks: "No one reads his books any more, no one puts on his plays, no one in fact knows his name, except, of course, the odd expert like yourself" . Desmond's awareness of this social annihilation explains his almost desperate attempts at eluding its grasp on his individual sense of identity. It is in this sense that Caroline's commissioned work comes to symbolize for him a plank of salvation, the hope of being rescued from his social and public death. As Desmond sombrely observes: "For years they have called me cold and grey. For years they have decided that I was dead. I don't suppose that any of my books are in print any longer. You can change all that. My future is in your hands" . It is this mere prospect of social and public resuscitation that has a direct effect on his subjective well-being, understood as based on the individual's self-perception : "I feel quite buoyed up. The thought of a rosy future has cleared my mind" . The amelioration of Desmond's circumstances and subjective well-being are thus implicitly dependent on Caroline. This accentuates the representation of this oldest old character as lacking in agency and self-reliance, a lack often associated with the fourth age. It must be noted, however, that this lack is not inherent to Desmond's personality, but rather an attribute of the social construct of the fourth age which has been projected onto Desmond in his very old age, which has consequences on his subjective well-being. Desmond is purposefully constructed as an unsympathetic character, which initially facilitates the association of his persona with the abject. He is depicted as a womanizer in his young age, with an oedipal relationship to his mother, a self-absorbed despot to his second wife Anna, whom it is suggested he has physically abused at least once in his old age, and who obsessively and secretly records his memories using an old tape-recorder. This negative depiction is supplemented with Desmond's manifest dissatisfaction with his experience of advanced old age. He regrets the loss of physical and mental faculties, which he considers to be "inadequacies" of old age , and has been unable to maintain a social network, as he is on bad terms with his three children, and only sees regularly his ex-wife Pamela and a taxi driver who served with him during the Second World War. His views on aging and his life prospects suggest a loss of a joie de vivre. Thus, in a conversation with his first wife Pamela, he unabashedly complains about old age: "I hate old age, stiff and creaky, cranky, smelly" , and commenting on his wife's control over his diet, he observes: "she believes that with her help I will live forever. I do hope she's wrong" . Desmond's subjective perception of his aged self is purportedly not uncommon among the oldest old. Analyses of the degree of life satisfaction in the oldest old register a dramatic decrease among this group. As contended by Smith, Borchelt, Maier, and Jopp , "[i]t is suggested that the increased risk of frailty, loss of functional capacity, and poor health during the period of very old age . . . may place constraints on life satisfaction and overwhelm individuals to such a degree that they moderate their expression of well-being" . In his case, it is particularly relevant that, despite experiencing the normal, though not the worst, "inadequacies" of extreme old age, Desmond's low life satisfaction allegedly originates both in the social death which he endures as a consequence of his very old age, and in the psychological distress caused by his regretful re-examination of crucial and irreversible events in his young life which resulted from his dubious moral and ethical system. These events include the loss of what he regards as the love of his life and his cold-blooded, casual shooting of a Nazi officer the day after the end of the Second World War. By the end of the novel no resolution to these haunting memories is attained, which, together with the imposition of social death on his persona, has a direct effect in Desmond's sense of subjective well-being. Consequently, the narrative does not suggest a sense of growth through reminiscence and life-review conducive to successful aging, as is often observed from the perspective of this paradigm . The narrativization of Desmond's experience of aging is significantly characterized by a mismatch between his explicit distaste with the effects of very old age, on the one hand, and his performance as a fully agentive fourth ager, on the other. Thus, for example, his insight into the manner in which social discourse others him on the basis of his advanced age belies a degree of mental alertness that counters the frailing discourse of the social imaginary of the fourth age. In terms of his physical condition, the fact that he still lives at home with his wife, and can move around Dublin without any help or support, apart from using the service of his friend as a taxi driver, suggests a degree of physical independence that clashes with his perception of old age as "stiff and creaky" . Regarding his social self, this has certainly been reduced with age, but he still has his wife and meets up regularly with his first wife, as well as with his former war companion. Thus, the clash between Desmond's self-expression about his old age and his own physical and intellectual performance as an oldest old serves to underscore that there has been a certain degree of interiorization of the social imaginary of the fourth age, and an experience of extreme old age under the influence of this imaginary that affects his sense of self when faced with what he perceives as the "precariousness about the present," as suggested by his reflections upon aging . --- Naming the Stars: Reminiscence and Sociocultural Context, Not Conducive to Successful Aging Johnston's novella Naming the Stars revolves around the narrative of two female characters, Flora and Nellie, which is mostly dominated by the latter's reminiscing of the circumstances that explain her life development and present state of near confinement. Flora, the last known surviving member of an Anglo-Irish family, and her lifelong maid Nellie, are the only inhabitants of the family's old country house. The narrative is set in contemporary Ireland, though the physical setting and the choice of protagonists is reminiscent of the Big House novel, a characteristically Irish literary subgenre which focuses on narrating the gentry life of the Protestant ascendancy, a social class identified with the plantation processes of the 16th and 17th centuries and, therefore, with the colonial presence of the English in Ireland. As literary critic Vera Kreilkamp contends, one of the characteristic features of these novels is that they imply a dialogic engagement of the fictional narrative with the historical narrative of this social class and their historical moment . Johnston's novella contains elements of this literary subgenre, such as the sense of a social class that was dying out at the time in which these novels were written, and the presence of childless aged female characters belonging to this class as well as pseudoderelict country houses as symbols of this class on the wane. However, Johnston's text relegates to the background the "responsiveness to issues of national identity that distinguishes the nineteenth-century Irish novel" , and foregrounds instead the aging experience of its protagonist. The narrative examines how the sociopolitical and cultural circumstances not just in Flora's late life, but also in her earlier life are decisive in her development and, ultimately, in her experience of advanced old age. To a certain extent it can be argued that, by focusing on the development of the female aged protagonist, this novella shares with the literary subgenre of the Big House novel the "responsiveness" to sociocultural developments in the national context of contemporary Ireland. In Johnston's text, however, this does not relate to matters of national identity, but rather to national concerns regarding the exponential growth of those aged 80 years and over, which have become increasingly present in the Irish political agenda over the last few years . To illustrate the origin of these concerns, it may suffice to note that it is estimated that, in the Republic of Ireland, whereas in 2006 the number of those aged over 60 was 462,000 people, by 2036 there will be a 250% increase and by 2041 it will have tripled. The greatest increase is, however, in those aged 80 years and over, where it is estimated that, compared with the population in this group in 2006, by 2041 the population will have quadrupled . The two female characters featured in this novella are in their eighties and, though Flora is 5 years younger , Nellie is seemingly a living example of "active aging," as she takes care of all house chores, runs any errands on her bicycle and takes care of Flora, with whom, as apparent from their conversation, she has developed a sense of mutual close companionship. Despite the lack of any evident physical impediment, Flora is noticeably inactive, with her existence confined to the limits of her Big House. Over the course of a single September evening, Flora's reminiscence gradually unveils psychological trauma in childhood and early adolescence as the possible explanation for her secluded existence. This experience relates to examinations of adult development models and the extent to which distal influences and past traumatic experiences may impact on life development and subjective well-being in advanced old age . In the case of Flora, there are two specific traumatic experiences that, as revealed through her reminiscence, have affected her "developmental trajector[y]" . The first of these experiences is the loss, at the front during the Second World War, of the two family members to whom she was most closely attached, namely her father in El Alamein, North Africa, and Eddie, her only sibling and elder brother, in Normandy, just 2 years after the tragic loss of their father when she was in her early teens. It is intuited that the dramatic damage to Flora's subjective well-being, caused by these losses at a crucial developmental stage in her life course, led to her mental instability and consequent institutionalization. However, the fallacy of this official narrative of Flora's life, as well as the actual trauma that explains her present circumstances are revealed in the secret that Flora unveils to Nellie, namely her pregnancy resulting from a one-night incestuous intercourse with her brother, under the effects of alcohol, trauma, and isolation, the night before he left the family home to secretly volunteer for war service. Flora's trauma, however, was not caused by the personal experience of being made pregnant by her brother, but by the socialization of this circumstance under the restrictive conservative morality of Ireland at the time. It is in this sense that a consideration of the sociocultural conditions of an individual's aging becomes crucial in order to gain a more nuanced understanding of subjective well-being in old-old age as well as the reasons behind an individual's apparent failure to age successfully. As Riley observed in her criticism of Rowe and Kahn's 1997 revision of their successful aging paradigm, "it fails to develop adequately the social structural opportunities necessary for realizing success" . In this sense, Riley contends that "successful ageing [depends] upon structural opportunities in schools, offices, nursing homes, families, communities, social networks, and society at large" . In Johnston's novella, Flora stands as a case in point of the negative consequences for individual aging when these micro, meso, and macro social structures fail to offer the necessary support to deal with psychological distress in an adequate manner. Thus, upon discovering Flora's pregnancy, she is confined by her mother to a mental institution, which Flora refers to as a "home from home for the harmlessly insane" , and which is evocative of the ignominious Magdalene asylums , mid-nineteenth-century homes initially aimed for the reformation of prostitutes. However, in later years, these institutions also de facto incarcerated other "'fallen' women-sexually active, unmarried women; victims of rape, incest and abuse; and women convicted of infanticide or concealment of a birth-as well as women considered to be at risk for a moral fall because they were too pretty, mentally disabled or ill, . . ." . Although initially established as social institutions by Protestant reformers in colonized Ireland, in the Irish context, the running of these institutions was taken over by Roman Catholic orders after the establishment of the Irish Free State in 1922 , when these institutions were turned into commercial laundries as a source of income for the orders that run them. These institutions functioned until 1996, when the last Magdalene laundry closed in Waterford city, in southern Ireland. Although Flora initially does not relay the father's name, upon revealing it, Flora is tagged as "mad," or temporarily mentally disabled, and in need of being stabilized before being released. In this manner, the restrictive social mores in 1940s Ireland enabled her mother and the institution to which she was confined to take recourse to the medical model of disability, which often regards it as "a personal tragedy that can sometimes lead to the blaming of the individual for his or her condition and the labelling of people with disabilities as 'victims' or 'sufferers'" . As Bond and Rodríguez Cabrero contend, in this process of medicalizing disability, "[t]he solution for the individual is perceived as medical treatment in order to 'cure' the condition, manage the symptoms and maintain the individual's adjustment to the disability and subsequent behaviour change" . As a result of this medicalization of what was socially regarded as immoral-and illegal, according to the Punishment of Incest Act 1908-behavior, Flora is confined to this institution for the duration of her youth and most of her adult life. When released aged 49, and only after her mother's death, she returns to the family home, which she never leaves again, avowedly as a consequence of her long-term institutionalization. As with Desmond in Truth or Fiction, Nellie's reminiscence concludes with no obvious acquisition of wisdom or discernibly positive outlook towards the future. In this sense, both fictional texts subvert the expectations of Constance Rooke's Vollendungsromane . Rooke's classification of the novels of completion or "winding down" identifies as characteristic of these texts an aged protagonist who, often through reminiscing and reviewing crucial past events, "is able to impart some wisdom regarding the end of life" . This wisdom also frequently allows these characters to attain a sense of "personal completion" and to reengage with their existence in a manner that suggests the realization of gerotranscendence, which Lars Tornstam defines as "a shift in metaperspective from a materialistic and rational view of the world to a more cosmic and transcendent one, normally followed by an increase in life satisfaction" . Desmond's and Flora's narratives do not suggest a gerotranscendent approach to their existence. Even Flora's final scene, naming the stars with her companion Nellie, reeks of escapism rather than inviting a more positivistic, cosmic connection with her existence and her place in the universe. This is particularly the case as naming the stars was a pastime of Nellie after watching Hollywood films in the local cinema in her youth, an activity which, as Nellie observes, would allow her to "touch . . . the world, not just [being] stuck at the bottom of a muddy hill in County Wicklow" . This apparent cosmic connection functioned rather as an imaginative escape which would sweep her away from her everyday life as a young maid in the Big House where she ended up spending the rest of her life. --- Conclusion In recent years, the exponential growth of the oldest old population has attracted increasing scientific interest in this segment of the population, which had remained largely unexamined. Analyses of the oldest old and the social imaginary of the fourth age have emphasized, among other factors, the need to pay greater attention to the diversity of individual experiences of aging and to consider the sociocultural conditioning of aging. They have emphasized the need to gain greater awareness of the different ages of old age, and to analyze, in particular, the specificity of advanced old age, remarking on the high degree of variability relating to the subjective experience of aging among the oldest old. This diversity, however, has not always been reflected in longitudinal studies . This is one of the reasons why a combination of this type of analyses with case studies can provide a more accurate knowledge of the experience of advanced old age. This will consequently offer a more nuanced understanding of this period of late life, which will ascribe more concrete knowledge to the fearful unknowability of the fourth age and thus contribute to rethinking this social imaginary. In this sense, literature, as exemplified here with the case of Johnston's texts, can fruitfully contribute fictional narratives of aging individuals who, like Desmond and Flora, would otherwise fall through the gaps of studies of old age. Their stories are a necessary component in order to gain a more mature understanding of how aging, and particularly advanced old age, incorporates gains and losses, and of the fact that the manner in which these are experienced varies individually and in relation to sociocultural and historical conditioning. With regard to this mature perspective, when asked in an interview whether the marriage between the characters of Laura and Maurice as described in her novel The Invisible Worm is "positive," Johnston replied: "It's mature. In the real world, people have to compromise. Life is a series of complex negotiations" . Through the individual aging experience of her oldest old characters of Desmond and Flora, Johnston's latest fiction highlights the need for this "series of complex negotiations" between gains and losses, positive and negative experiences of aging, to be incorporated into scholarly analyses of narrativizations of the aging experience. In line with Baars's advice, Johnston's fictional texts look advanced old age in the eye in order to contest the frailing and abjection of the fourth age.

Background and Objectives: Associations of young-old age with successful aging have contributed to relegating negatively perceived aspects of aging to very old age. This has prompted the formation of the social imaginary of the fourth age. Re-examinations of the fourth age foreground the diversity of aging experiences among the oldest old. In this sense, literature is in a privileged position to contribute individual narratives of aging to this field. The main aim of this article is to analyze Irish writer Jennifer Johnston's later fiction and how particularly two of her later fictional works contribute a nuanced re-examination of the fourth age through the narrativization of individual aging experiences of the oldest old in the contemporary Irish context.The work of sociologists and social theorists on re-examinations of the fourth age functions as the framework to analyze the selected fictional texts. Results: The analysis of the oldest old characters in Truth or Fiction and Naming the Stars shows the contribution of literary texts to rethinking the fourth age as a time characterized by the inextricable combination of gains and losses, with emphasis on the diversity of the aging experiences of the oldest old and on the importance of sociocultural influence on individual aging. Discussion and Implications: Combining longitudinal analyses with case studies, such as the ones suggested by these fictional texts, can provide a more accurate knowledge of the experience of advanced old age and the fourth age.

Introduction There are over half a million cervical cancer cases diagnosed annually making it the third most common cancer in women worldwide. [1] Additionally, it is the leading cause of female cancer deaths in Se ´ne ´gal with an estimated 1,876 cervical cancer cases diagnosed annually with 1,367 deaths resulting in a age-standardized mortality rate of 29.1 compared to 6.9 globally. [2] The age-standardized cervical cancer incidence rate in North America is 7.6/100,00 women compared to 23/100,000 in Western Africa and 37.8/100,000 in Se ´ne ´gal, ranking it the 17 th highest incidence in the world. [3,4] Despite the effectiveness of cervical cancer screening and treatment in reducing incidence and mortality, [5] the estimated participation rate for cervical cancer screening in Se ´ne ´gal is very low . It is especially low in rural areas and in older age groups . [6] Cervical cancer screening remains unavailable in many rural areas of Senegal but has been accessible throughout the Ke ´dougou region of Se ´ne ´gal since 2014 through the efforts of an ongoing partnership. [7] Cervical cancer is both preventable and concentrated in lowand middle-income countries [8] with over 85% of global cervical cancer deaths occurring in LMICs. [3] The high incidence and mortality of cervical cancer is an important indicator of larger health system problems, including poor access to care and screening and the lack of culturally competent communication; factors that disproportionately affect poor women. [9] Gender is recognized as an important social determinant of health. [10] In many contexts there is a structural disadvantage for women that goes beyond the fact of the illnesses affecting them. Nuanced gendered perceptions and health behaviors of both women and men play a significant role in women's ability to access the care that they need. [11] Men or older family members are often the decision makers for when and how women may gain access to healthcare. [12] In addition, when women are empowered, their increased decision-making autonomy and access to economic resources have a positive effect on their use of healthcare services. [13,14] Conversely, perceived discrimination reduces the likelihood of seeking cervical cancer screenings, [15] and shame and stigma limits women's overall use of health services. [12] Previous studies have found important gender differences for stigmatized illnesses such as HIV/AIDS and mental illness in LMICs. [16][17][18][19][20][21][22] In Kenya and Pakistan, women had higher personal stigma attitudes than men toward HIV/AIDS, depression, and HPV infection. [18,21,23] There are also gender differences for acceptability of treatment, including seeking psychological help and getting vaccinated. [16,24,25] Many of these studies emphasize the need to incorporate gender-specific components in interventions to increase acceptability and healthcare utilization. [16,17,21,24,26] For example, a study found male-female differences on effective strategies to increase HPV vaccine acceptability: for men, it was most effective to correct misconceptions, promote healthcare provider recommendations, and emphasize perceived benefits, whereas for women, it was more important to address gender norms and discrimination. [24] A meta-analysis on gender differences related to HPV vaccine acceptability found similar results. [17] There is limited research on stigma associated with cervical cancer. Social stigmas around sexual behavior and HPV infection [27] may contribute to vaccine and screening hesitancy. Social stigma can manifest as personal stigmas or as perceived public stigmas . [28] In addition, the expression of attitudes related to stigma is moderated by social influence-that is by the ability of individuals to affect one another's thoughts, ideas, and behaviors. [29][30][31] In these ways, negative social influences play a role in spreading negative behaviors [29,32] and may be linked to cervical cancer screening hesitancy. Understanding how these factors contribute to the acceptability and adoption of cervical cancer prevention is of paramount importance. A broader knowledge of the relationship of gender differences within stigma, discrimination, and acceptability may help to improve the global response to cervical cancer. Our study analyzed gender differences on perceptions of gender roles, discrimination, cancer attitudes, cancer stigma, and influences in healthcare decision making within our study population. --- Methods We conducted a cross-sectional survey of 158 participants, 101 women and 57 men across nine non-probability-sampled communities in the Ke ´dougou region of Se ´ne ´gal from October 2018 through February 2019. We collected demographic information and data on health service utilization, cervical cancer knowledge, and experience of cervical cancer screening through interviewer-administered surveys. The surveys were administered to one woman and one man per 10 randomly selected households and five women per women's group within each community. Survey interviews were conducted in the participants' choice of language: French, Malinke, or Pulaar. Participants were eligible for inclusion in the study if they were between 30-59 years old and were female or were a male living with a female who is able to seek cervical cancer prevention services from a health facility in the Ke ´dougou region of Se ´ne ´gal. Participants who were outside the target age-range were not eligible for participation. --- Site selection and recruitment The region of Ke ´dougou is divided into three medical districts: Ke ´dougou, Saraya, and Salemata. Each of these health districts has a single health center in the district capital and multiple health posts in the rural surrounding communities. We selected nine sites in the Ke ´dougou Medical Region through non-probability sampling including one health center and two rural health posts from each of the three districts comprising the region. In the Ke ´dougou District we selected the Dalaba health post , Bandafassi , and Dindefello . In the Salemata District we selected the Salemata Health Center and the health posts of Dar Salaam and Dakately . In the Saraya District, we selected the Saraya Health Center and the posts of Nafadji and Khossanto . Each of the nine sites was mapped through OpenStreetMaps. [33] Printable maps were created to illustrate structures , roads, and rivers in each site. Maps were divided into four sectors with approximately the same number of structures in each quadrant. Structures were numbered and Google's random number generator was used to determine the starting point. Counting in increments of the limiting factor, each chosen structure was marked and recorded. This ensured a relatively even distribution of structures selected throughout each site. Twenty structures per site were selected and visited in order to assess for eligibility. Potential participants were recruited using the approved recruitment script. Households were selected if there was both an eligible woman and man who agreed to participate. An additional five women were recruited in each site from among the women's group to strengthen the assessment at the community level. The target sample size of 225 was determined based on the need to have a heterogeneous sample across language and district. Our sample was not adequately powered to detect differences between screened and unscreened women. --- Development of documents The questionnaire included closed-ended, quantitative questions seeking information on participant's perceptions of discrimination, cancer stigma, opinions, and attitudes. We included adapted questions from the Everyday Discrimination Scale [35] and the Cancer Stigma Scale. [36] The questionnaires were first created in English, translated into French and the local languages of Jakhanke/Malinke and Pula Fuuta , and then back-translated for accuracy by certified Se ´ne ´galese translators. Questionnaires were field tested for comprehension prior to the initiation of the study. All IRB approved documents including study overview, recruitment scripts, and the informed consent were available in French, Malinke, and Pulaar. --- Consent and data collection All research assistant data collectors participated in a three-day training on the project protocol including data collection methodology facilitated by the lead investigator prior to field testing the instrument. After final institutional review board approval, research assistants attended an additional three-day training to review all data collection procedures. The study research assistants read the informed consent aloud, in the participants preferred language, and participants reviewed and signed the approved informed consent short form, written in French. In cases where the participant did not read French, a trusted contact was requested by the participant to witness the informed consent process, observe the signature of the participant, and then sign as a witness. After participants were consented, data collection was conducted immediately with a female research assistant collecting data from women and a male research assistant collecting data from men. All data collection activities were performed in a private setting. Data collection interviews occurred in the preferred language of the participant. All responses were recorded on hard copy interview forms with the name of the participant being the only item recorded on the final page. All data collection instruments were immediately handed over to the lead research assistant, who recorded the participant's name on the participant code book, placed a unique identifier on page one of the data collection instrument, removed and destroyed the final page of each instrument, scanned all documents, and transmitted them through a secure portal to a research assistant in the United States. --- Data analysis Data were double-entered into an electronic spreadsheet by two research assistants, compared, approved and subsequently cleaned by the principal investigator. Bivariate analyses were conducted to 1) assess gender differences in the distribution of all variables including the adapted everyday discrimination scale, cancer stigma scale, and various cervical cancer attitude measures; 2) determine whether there were significant differences in beliefs and attitudes by screening behavior; and 3) explore the potential effect of educational attainment on gender differences in attitudes and beliefs. To accomplish the third analysis, we created a composite variable combining gender and education, categorizing those with Quranic school or no school as having "Low Education" and those who attended primary school, secondary school, and above as having "Higher Education." Associations were tested using the Fisher's Exact test statistic . --- The conduct of responsible research and partnership The University of Illinois at Chicago has an ongoing partnership affiliation agreement with the Institute of Health and Development at the University Cheikh Anta Diop and with the Medical Region of Ke ´dougou. This partnership uses a participatory approach ensuring that all activities are well-aligned with the expressed priorities of the local health system. This human subjects research was approved by the University of Illinois at Chicago Institutional Review Board and the Institutional Review Board at the Ministry of Health and Social Action in Senegal. The Medical Region of Ke ´dougou, the three health districts, and participating health posts granted researchers permission through signed letters of support to implement and conduct the data collection activities. Each investigator and U.S. based research assistant received the Collaborative Institutional Training Initiative training certification prior to conducting the research. [37] All local research assistants were trained in research ethics through a locally approved ethics of human research training program. --- Results Our enrollment goal was 225 . With 158 participants , we achieved a functional response rate of 70.2%. The response rate for women was appreciably higher than for men . The mean age of participants was 41.6 with the mean age of men being slightly higher than the mean age of women . The distribution of participants across sites is reported in Table 1. There were significant gender differences in educational level . Among those surveyed, 97% of all women and 76.8% of all men had no more than a primary education while 25.7% of women and 10.3% of men had no formal education at all. No women in our sample attended more than two years of secondary school while 8.9% of men were educated beyond two years of secondary school and an additional 7.1% had at least some university education. The majority of participants were married, and among all women, 51.5% were in a polygamous household . The majority of our sample speaks one or both prevalent local languages, Malinke and Pulaar . As is characteristic for the region, there are fewer Wolof and French speakers in our sample. It should be noted that there are significantly more male Wolof than female Wolof speakers as well as male French than female French speakers . Among the women in our sample, 84.2% have never been screened for cervical cancer, 13.9% have been screened one time, and 2.0% have been screened multiple times. We found significant gender differences regarding the perception of a woman's role and a man's role . Among women, 7.0% agreed and 59.0% strongly agreed that a woman's most important role is to take care of her home and cook for her family, while among men, 43.9% agreed and 40.4% strongly agreed with this statement. Concerning a man's role, 14.9% of women agreed and 53.5% strongly agreed that a man should have the final word about decisions in his home, while among men, 23.2% agreed and 69.6% strongly agreed. Within our study population, we found significant gender differences in the everyday discrimination questions of "decreased respect by spouse" and "others act toward them as if they are not smart" . Specifically, 48.0% of women and 78.8% of men stated that they never experienced disrespect by their spouse, while, in contrast, 14.3% of women and 0% of men stated that they are treated with less courtesy or respect by their spouse on a daily basis. Men were significantly more likely to feel that others acted as if they are not smart. Of the men who stated that they perceived this type of discrimination, 32.1% stated that this occurred a few times in their life, 9.4% that it occured a few times per year and none stated that it occured weekly or daily. Within our study, 78.2% of women and 58.5% of men stated that they were never perceived as unintelligent by others. Of the women who stated that they perceived this type of discrimination, 15.8% stated that this occurred a few times in my life, 4.0% that it occured a few times per year and 2.0% stated that it occured weekly or daily. Most participants never felt perceived as being dishonest, and 81.8% never felt threatened by others. Regarding cancer stigma, we found significant gender differences for those who would not feel comfortable around someone with cancer , concerning perceptions of cancer patients being normal , the need to prioritize the needs of people with cancer , perceptions of a cancer diagnosis being the fault of the individual , that cancer is more frightening than other diseases , and that women worry about getting cancer . Among women, 19.0% agreed and 25.0% strongly agreed while among men, 16.1% agreed and only 1.8% strongly agreed that "I would not feel comfortable around someone with cancer." Among women, 31.0% agreed and 57.0% strongly agreed while among men, 41.1% agreed and 8.9% strongly agreed that once you've had cancer you're never 'normal' again. Among women, 31.3% agreed and 32.3% strongly agreed while among men, 3.6% agreed and 5.4% strongly agreed that the health care needs of people with cancer should not be prioritized. Among women, 16.0% agreed and 27.0% strongly agreed while among men, 12.5% agreed and 1.8% strongly agreed that if a person has cancer it's probably their fault. Among women, 34.3% agreed and 50.5% strongly agreed while among men, 36.4% agreed and 16.4% strongly agreed that cancer is more frightening than most other diseases. Among women 48.0% strongly agree while only 7.1% of men strongly agree that other women often state that they are worried about getting cancer. We found no significant difference between women and men in stating that "I would feel sorry for someone with cancer." Among all respondents, 48.1% agree and 40.4% strongly agree. We found significant gender differences for certain cancer related attitudes such as the need to get cancer testing or treatment even if it is unpleasant , the desire for family to know of a personal cancer diagnosis , and the personal desire to know of a cancer diagnosis in a family member . Among women, 18.0% disagreed and 10.0% strongly disagreed while among men, 3.6% disagreed and 1.8% strongly disagreed that "If I had cancer, I would want my family to know that I have it." Among women, 25.3% disagreed and 4.0% strongly disagreed while among men, 0% disagreed and 1.8% strongly disagreed that "if someone else in my family had cancer, I would want to know that they have it." Among all respondents a considerable number agreed or strongly agreed that cancer testing or treatment that is unpleasant is worth getting if it would help them to live longer. In addition, among all respondents a considerable number agreed or strongly agreed that if they had cancer, they would want to know that they have it. Among all respondents, 32.1% agreed and 11.5% strongly agreed that getting a serious disease like cancer is fate, there is nothing they can do to change fate. When making decisions about one's healthcare, women are more likely than men to trust social contacts such as their spouse , their children , while women are more likely than men to state that their spouse has the final say . When women were asked, specifically, about opinions regarding their decision to get screened for cervical cancer, 55.4% of women stated that the head of the household would be most influential. Although there were no statistically significant gender differences in questions related to screening recommendations, it is noteworthy that among all respondents, 19.7% strongly agree, 41.4% agree, and 32.5% remain undecided that overall, other women that they know recommend the cervical cancer test. In addition, 49.4% strongly agree, 37.2% agree, and 9.0% remain undecided that they would recommend that women get routine testing for cervical cancer. --- Screened correlation Subsequently, we correlated all variables with screening behavior among women. S1 Table lists these results. Among women who have been screened once, 92.3% strongly recommend that other women get screened compared to 44.0% of women never screened. Among women who have never been screened, 48.2% disagree and 4.7% strongly disagree that they would not feel comfortable around someone with cancer. However, among those who have been screened a single time, 15.4% disagree and 46.2% strongly disagree with this statement . Among women who were screened one time, 61.5% strongly agreed that if a person has cancer it's probably their fault compared to 22.4% of women who have never been screened . In addition, 76.9% of women who have been screened one time strongly agreed that other women often state that they are worried about getting cancer compared to only 44.7% of women never screened . In correlating cancer attitudes with screening behavior we discovered that 91.7% of women screened a single time strongly agreed that they would want to know if they were diagnosed with cancer compared with 49.4% of women never screened . However, results indicating desire for a family member to know about diagnosis were insignificant. It is notable that on this question nearly half of those who had been screened one time either disagreed or strongly disagreed that they would want a family member to know about their diagnosis compared to 17.6% and 8.2% respectively for women never screened. We found that among both women who have never been screened and those who have been screened one time, most prefer to know about the diagnosis of someone else in the family. Of those who have never been screened, 40.5% agree and 29.8% strongly agree that they would want to be informed. Among those screened once, 15.4% agree and 53.9% strongly agree that they would like to be informed of a family member's diagnosis. Among women screened a single time, 61.5% strongly disagreed that cancer is fate and there is nothing they can do to change fate compared with 18.8% of never screened women who strongly disagreed with this statement. --- Education effect on gender perceptions In examining the effect of education on gender perceptions across all variables, it should be noted that 97% of the women in the study received no more than primary education, while 23.1% of men received some secondary schooling or above. We, therefore, compared the effect of Quranic school or no education to primary education or above across all variables. Through this analysis, we identified statistically significant findings for education level relative to perceptions of a woman's role as caretaker and a man's role as decision maker . Among women with "Higher Education" 47.5% disagreed with the statement "A woman's most important role is to take care of her home and cook for her family" and only 11.7% of women with "Low Education" disagreed while among men, 3.8% and 16.7% of those with "Low Education" and "Higher Education" respectively disagreed. Among women with "Higher Education" 37.5% disagreed with the statement "A man should have the final word about decisions in his home" and only 14.8% of women with "Low Education" disagreed while among men, 10.3% of those with "Higher Education" disagreed. No men classified as having "Low Education" disagreed with this statement. Concerning the adapted everyday discrimination scale analyzed with the gender-education composite variable, we found significant results for a) 'generally feel treated with less courtesy than others' , b) 'feel treated with less respect by their spouse,' c) 'perceived as unintelligent by others' , d) 'feel perceived as being dishonest' , and e) 'feel threatened by others' . Regarding the adapted cancer stigma scale, we found significant results regarding a) 'comfort with being around someone with cancer' , b) 'those diagnosed with cancer are no longer normal' , c) 'the healthcare needs of people with cancer should not be prioritized' , d) 'having cancer is probably the fault of that person' , e) 'cancer is more frightening than other diseases' , and f) 'other women often state that they are worried about getting cancer' ,. Illustrating this effect of education, we found that 59.0% of women with "Higher Education" disagreed that having cancer is the fault of that person, while 27.9% of women who had "Low Education" disagreed with this statement. Among men, we found that 50.0% and 34.5% of those with "Low" and "Higher" education respectively strongly disagreed with the statement. In addition, we found significant effect of education on gender perceptions on other cancer attitudes including: a) the value of cancer testing, even if unpleasant , b) desire to be informed about one's personal cancer diagnosis , c) desire for family to be aware of one's cancer diagnosis , c) desire to know of cancer diagnosis for another family member , and d) getting cancer is fate . We did not find any significant impact of education on gender perceptions of recommendation for the cervical cancer screening test. --- Discussion We have identified differences by gender in the perception of gender roles, everyday discrimination, cancer stigma indicators, other cancer-related attitudes, trusted opinion in healthcare decisions, and autonomy in healthcare decision-making. These findings reveal structural gender disadvantages and important insights related to social influences that may play a role in decision-making and screening behavior. Our findings concerning social influences are valuable in illustrating the importance of better understanding key social norms. --- Structural gender disadvantages Our data reveal some structural disadvantages for women within our study population. Women were less educated than men, and, in turn, were less likely to speak the national languages, Wolof and French. Education and language are both meaningful social determinants of health [38] and may be indicators of status and empowerment, both of which are key to accessing healthcare within this population. In addition, the social role for women in Southeastern Se ´ne ´gal appears to be largely agreed upon between women and men. In this region, women generally work in the home and men conduct business and make decisions on the part of the family. Somewhat more women than men disagreed with these prescribed roles lending weight to the desire by some women for more autonomy. Our data also indicate gender differences among variables in the adapted everyday discrimination scale within this population. Women were much more likely to state that they are treated with less courtesy or respect by their spouse on a frequent basis. In contrast, feeling general disrespect outside of the home are not significant. This finding may, therefore, be closely tied to the accepted social roles of women and men. Interestingly, men were somewhat more likely to feel perceived as being unintelligent. We have no explanatory mechanism, but this phenomenon may be related to men being much more likely to take on the role of leader in business interactions. In doing so, men are much more likely to travel and engage with others who have higher levels of education. They, therefore, may be comparing themselves to a different audience than women. --- Attitudes and stigma Our findings indicate that women are much more likely to personally stigmatize cancer. Women are significantly more likely than men to state that a) they would feel uncomfortable around someone with cancer, b) someone with a cancer diagnosis is never normal again, c) the health needs of people with cancer should not be prioritized, d) if a person has cancer it is probably their fault, e) I feel that cancer is more frightening than most other diseases, and f) other women often state that they are worried about getting cancer. Both women and men agreed on the importance of seeking screening or treatment for cancer, as well as the desire to know personally about a screening result. However, we found a significant difference between women and men concerning the desire for others to know about a personal cancer diagnosis. We found a similar pattern concerning the desire to know about a family member's cancer diagnosis. This may indicate that women are also more likely to have a perceived stigma against cancer. These findings are intriguing and warrant further investigation. Higher rates of both personal and perceived cancer stigma among women has profound implications for how population and community level communication strategies for cancer prevention and control should be designed. Given that social norms play a critical role in the development of stigmas, we need a better understanding of the negative social influences that shape women's and men's knowledge, attitudes, and beliefs, as well as whether early positive social influences may be impactful in increasing early uptake for cancer prevention services. --- Social influences Our data show that women are much more likely to rely on the guidance and advice of their spouses or others within their immediate social network while men rely on the recommendations of health professionals when considering health care decisions. The large majority of women and men agree that it is the men who have the healthcare seeking decision making power at home. While the individual variables in our study are not altogether specific to cervical cancer, our data does indicate that both women and men would recommend the cervical cancer screening test to others. The perceived recommendation of the screening test from other women, however, is not as considerable. --- Screening behavior Women who have been screened are much more likely than non-screened women to recommend that other women get routine cervical cancer screening. In addition, it appears that they are less likely to display personal stigma toward cancer patients as evidenced by disagreement with having discomfort around a cancer patient. Screened women do note that other women are worried about getting cancer. If they were personally diagnosed or someone in their family were diagnosed, they would overwhelmingly want to know. However, on the question to inform family members of their own diagnosis, they are split. Further inquiry to explore this contradictory finding could pursue whether some women prefer others not be informed of a diagnosis because of shame, perceived stigma, stoicism, or other potential reasons. Interestingly, screened women tended to strongly agree that a diagnosis of cancer is the fault of the person. Even though all questions were field tested, this may indicate confusion underlying the premise of the question. It is not possible to know if the women who responded in this way have responded specific to the context of cervical cancer and are indicating that they feel that screening is a way to prevent this illness, and, therefore, it is the responsibility of the individual to seek this service. Lending weight to this supposition is the fact that 61.5% of screened women strongly disagreed that cancer is fate. This significant finding illustrates the importance of ensuring that women feel empowered to prevent cervical cancer through screening by ensuring that stigma, attitudes, and beliefs are prioritized through outreach efforts aimed at uptake. --- Effect of educational achievement on gender perceptions Our findings exploring the effect of educational achievement on gender perceptions have considerable implications for future work. Concerning a woman's role, there is a clear correlation with increased education among women and men and disagreement with the statement outlining a very traditional perspective. Likewise, increased levels of education indicate that both men and women are more likely to disagree that men are the sole decision maker in the family. We see similar attenuation of gender specific findings on the adapted everyday discrimination scale, the adapted cancer scale, and other cancer-specific attitudes and opinions. This brings to light critical questions to be addressed through future research, the results of which could impact the development of educational, behavioral change, and social mobilization focused interventions aimed at cancer and, specifically, cervical cancer prevention and control at various levels . --- Confronting barriers and context Our findings that illustrate that gender roles in decision making, gender influences in discrimination and cancer stigmas, and other structural barriers such as educational attainment and language are meaningful social determinants of health related to cervical cancer screening uptake in Senegal. The existing literature exploring these themes is not robust but presents some insights that may be helpful in further interpreting our findings and guiding our next steps. As an example, cultural norms, gender roles, knowledge, and stigma were identified as socio-cultural factors influencing a woman's decision to seek cervical cancer screening in disadvantaged communities in Cape Town, South Africa. [39] In addition, a study in Cusco, Peru linked underlying determinants such as fear, embarrassment, community conversations about cervical cancer, willingness to talk about cervical cancer, and gender dynamics, including spousal support, to health communications preferences. They found that cultural misconceptions and male perspectives were significant factors predicting screening uptake with an overwhelming need for interventions addressing sociocultural influences in order to address the underlying root causes. [40] These findings suggest that behavior interventions aimed at increasing the uptake of cervical cancer screening services should utilize strategies that go beyond simple health communication and education. In fact, one study examining factors related to breast and cervical cancer screening uptake among Cambodian and Thai women in Southern California identified similar structural barriers that these women were, in large part, unable to overcome such barriers without the assistance of a community navigator. [41] While it is critical to address knowledge gaps, our challenge will be to concurrently address underlying social determinants of cervical cancer screening uptake through positive social influence. --- Limitations There were some limitations in the methodology used to recruit households within each site. It was assumed that every structure identified on the map was a household and it was thus, included in the count because specific household information was not provided. In reality, some structures were businesses, vacant, or not present. When encountering this scenario, we progressed to the next marked structure on the list. In addition, the satellite images used to create the maps on OpenStreetMaps may have been outdated. In some cases data collection was attempted separately from the recruitment and consent process. This may have resulted in the inability to collect data from some of the selected households due to the participant being away during the day that the research assistant was present. Considerable effort was made to select communities that are representative of the immediate and surrounding districts and regions of rural Se ´ne ´gal. However, our sample may not be generalizable to other areas of Se ´ne ´gal or other countries in West Africa. In addition, we must use caution in interpreting these results given the low numbers of women within our study sample who have been screened for cervical cancer. We will follow the trend of these indicators over time as women are exposed to the peer education program. --- Conclusions The findings concerning social influences are valuable in illustrating the importance of better understanding key social norms and the contexts in which they are found or implicated. Our findings illustrate the critical need, as well, to recognize gender differences concerning social influences within the same context. By detailing the potential negative social influences that can directly act as or contribute to barriers to healthcare services utilization, community outreach activities including social and behavior change communication strategies aimed at these factors can help to overcome existing challenges in cervical cancer prevention and control. Furthermore, the development of innovative interventions such as patient navigation programs that incorporate or leverage positive social influences may prove useful in optimizing health services uptake such as HPV vaccination and cervical cancer screening earlier and more effectively. Our study also illustrates that gender norms should be routinely considered in efforts aimed at improving uptake of cervical cancer health services in the rural region of Ke ´dougou, Se ´ne ´gal. In this vein, women's likelihood of being more susceptible to some types of everyday discrimination should guide discrete and sensitive interventions at the health service level as well as within the community setting. Women's greater likelihood of harboring personal stigma and being susceptible to perceptions of perceived stigmas should be openly and proactively addressed through the identification and interruption of negative social influences while positive social influences aimed at overcoming these sensitive challenges should be fully leveraged. Likewise, attitudes and opinions that indicate that men currently maintain a considerable role in the healthcare utilization process should be emphasized in the short term and coupled with parallel activities that seek to empower women in the long-term. Men's role in advancing education and healthy healthcare decision making through positive social influence should be leveraged alongside efforts focused on women. The differences observed in the analysis exploring the effect of education on gender perceptions illustrate that some gender differences may be attenuated with more knowledge and advancement through formal education. However, it is important to recognize the underlying social fabric in this rural region as the immediate context in seeking the goal of increased health service uptake for cervical cancer screening services here. The reality of this somewhat isolated and underdeveloped region is that social determinants such as gender impact efforts aimed to improve cervical cancer prevention and control in the region. It is critical, of course, to consider a human rights approach and address underlying social determinants through a long-term vision. However, the reality of uniformly advancing education and addressing existing cultural influences that result in social norms that are considered problematic to achieving health equity is daunting. Therefore, efforts to advance the goal of the elimination of cervical cancer should, in the short-term, seek to gain a more profound understanding of the ways that gender, language, and other social determinants impact immediate barriers addressable through interventions. Social and behavior change communication coupled with a community-based patient navigation program may be one approach that can focus both on education while seeking to leverage the social influences that exist in achieving immediate and long-term goals.

Cervical cancer is the leading cause of female cancer deaths in Se ´ne ´gal which is ranked 17 th in incidence globally, however, the screening rate there is very low. Nuanced gendered perceptions and health behaviors of both women and men play a significant role in women's health. Our study analyzed gender differences on perceptions of gender roles, discrimination, cancer attitudes, cancer stigma, and influences in healthcare decision making within our study population to inform ongoing cervical cancer prevention work in the rural region of Ke ´dougou, Se ´ne ´gal. We conducted a cross-sectional survey of 158 participants, 101 women and 57 men (ages 30-59) across nine non-probability-sampled communities from October 2018 through February 2019. Bivariate analysis was conducted to assess gender differences across all variables. We also conducted analyses to determine whether there were significant differences in beliefs and attitudes, by screening behavior and by education. We found significant gender differences regarding the perception of a woman's role (P < 0.001) and a man's role (P = 0.007) as well as in the everyday discrimination questions of "decreased respect by spouse" (P < 0.001). Regarding cancer stigma, among women, 18.00% disagreed and 10.00% strongly disagreed while among men, 3.6% disagreed and 1.8% strongly disagreed that "If I had cancer, I would want my family to know that I have it." When making decisions about one's healthcare, women are more likely than men to trust

Background A clear gradient in health was recently observed in Canada among the more socially disadvantaged individuals [1]. It was observed that individuals with a lower socioeconomic status are more likely to adopt unhealthy lifestyle habits like smoking and being sedentary [2][3][4]. They are also more likely to have low quality diets and to face food insecurity [1,3]. Consequently, low SES groups are more likely to develop chronic diseases, such as cardiovascular diseases and type 2 diabetes, and to have a lower life expectancy [1,3]. Health inequalities are the result of interactions between multiple factors, including living conditions, psychosocial factors, health behaviours and genetic factors [1]. Despite this higher burden of diseases, individuals with a low SES do not always benefit from medical advances; this situation potentially leading to an increase in inequalities within the population [5]. Hence, health inequalities are a significant public health concern and reducing them represents a top priority [1,6]. Prospective cohort studies may support public health efforts in reducing health inequalities by providing knowledge about the causes of these inequalities [6]. Such studies may also provide ongoing monitoring of the population's health in the context of implementing and evaluating public health policies [1]. However, these studies, traditionally conducted by phone, postal mail or face-to-face interviews, can be burdensome and costly. Therefore, Web-based cohort studies raised enthusiasm in recent years due to their lower cost and time demand as well as the quality of data [7][8][9]. Web versions of a sociodemographic questionnaire [10], an anthropometric questionnaire [11] and a 24 h dietary recall [12] were validated in the NutriNet-Santé France prospective ecohort study. Researchers concluded that data obtained from the Web questionnaires were of equal or superior quality when compared to data obtained from the paperand-pencil versions of these questionnaires. Moreover, Web-based studies allow for an easier access to a larger number of potential participants, eliminating geographical boundaries and favoring easier access to hard-toreach populations [9,[13][14][15]. In general, Internet access is now less perceived as a barrier to participate in Webbased studies [14][15][16] and can even be perceived as a facilitating factor. Indeed, in the NutriNet-Santé France study, half of the participants reported that they would not have participated in the project if it had not been conducted on the Internet [16]. On the other hand, the use of Web-based methods for data collection in health surveys and cohort studies remains a challenge. The European Health Interview Survey has shown that the use of mixed methods for data collection yielded a higher participation rate than the use of Web-based methods only [17]. Furthermore, although the majority of families living with an income lower than $20,000 have access to Internet in the context of the present study, a digital divide still exists in societies [18]. Low SES individuals still report lower access to Internet in their household [18] and, in some cases, have lower levels of health literacy and computer literacy due to lower education levels [19]. Considering the growing popularity of Web-based cohort studies and surveillance efforts, implementing strategies to maximize participation of individuals with a low SES in such studies is critical. Moreover, since individuals with a low SES are generally underrepresented in health studies [20,21], recruitment and retention strategies must be adapted to encourage participation among these populations. Epidemiological and surveillance research aimed at addressing social inequalities in health does not come without challenges. Indeed, transportation and time constraints [22][23][24], residential instability [22,25], wrong numbers, disconnected phones and lack of answering machines [13,22,25], inability to reach potential participants at initial contact [25], economic constraints [23], mistrust of the Government and research, fear of exploitation as well as lack of knowledge [13,23,24] have all been identified as barriers to participating in studies among hard-to-reach populations such as those with a low SES, minority groups, and vulnerable populations. Hard-to-reach individuals are also often excluded from longitudinal studies because of acute medical or psychological conditions, or because of behavioural and social factors like alcoholism and drug abuse [23]. However, the barriers reported in these studies were not documented in the context of participation in Web-based prospective studies and were not conducted according to a validated theoretical framework. This is key because the use of theoretical frameworks to identify facilitators and barriers help in the development of more meaningful messages aimed at promoting the targeted behaviours [26]. To date, the very few studies that have used a validated theoretical framework to examine barriers towards participation in Web-based surveys were conducted among students or in the general population [27,28]. Thus, the perceptions and beliefs of individuals with a low SES towards participation in prospective cohort studies remain essentially unknown. According to the Theory of Planned Behaviour , the adoption of a given behaviour is determined by individuals' intention to perform the behaviour. In turn, intention is influenced by individuals' attitude , the subjective norm and perceived behavioural control [29]. A meta-analysis reported that the TPB could explain 19.3% of the variance of several health-related behaviours and 44.3% of the variance of intention [30]. The TPB showed moderate to strong prediction of intention and behaviours across several health domains [31]. In addition, studies have previously used the TPB to examine beliefs related to participation in Web-based surveys [27,28,32]. Other studies based on the TPB have also demonstrated how beliefs related to one's health can impact their decision to participate in health programs [33,34]. Given the strong predictive validity of the TPB [29] and its recognition as a rigorous tool to examine behaviours related to participation in Web-based surveys, this theoretical framework was used in the present study. A Web-based prospective study providing ongoing monitoring of the population's health could allow evaluating public health policies as well as identifying and addressing health inequalities. Since individuals with a low SES are generally underrepresented in health studies, recruitment and retention strategies must be adapted to encourage participation among these populations in this type of research project. To support the development of effective strategies to recruit and retain individuals with a low SES, the aim of this study was to examine the determinants of intention and associated beliefs among individuals with a low SES toward participation in a Web-based prospective study, the NutriQuébec project, using the TPB [29]. --- Methods --- Design and sampling The NutriQuébec project is a Web-based, prospective study aimed at examining the impact of nutrition-related public health policies and action plans on the diet of the Québec adult population in Canada. More broadly, the NutriQuébec project aims to examine the associations between diet and health outcomes. To do so, male and female adults are invited to complete a series of yearly core questionnaires through the Web, assessing dietary habits and other lifestyle habits , sociodemographic characteristics and general health. The time required to complete the core questionnaires on a yearly basis was estimated to two hours . Participants have a one-month period to complete the set of questionnaires. Participants may be invited to complete additional questionnaires on other nutrition-related issues between each yearly core measurements. A brief personalized assessment of dietary habits is returned yearly to each participant. A cross-sectional survey was conducted throughout the Province of Québec, Canada among adults with a low SES. Respondents were recruited through a Web panel of a polling firm. The polling firm uses a pool of panelists that were randomly recruited among the Québec population to complete online surveys. The polling firm then sends a request to fill out the survey questionnaire to panelists corresponding to the inclusion criteria. The inclusion criteria were 1) to be able to complete a questionnaire in French, 2) to reside in the Province of Québec 3) to have low education , and 4) to have low income . Overall, 1370 individuals were invited by the polling firm to complete the survey questionnaire . Among those, 708 individuals accessed the questionnaire but 383 participants were excluded from the study because they did not meet the inclusion criteria , accessed the questionnaire after data collection was completed , unsubscribed from the polling firm panel or stopped the questionnaire while completing it . Therefore, the data of 325 respondents were retained for analysis. The survey questionnaire was completed by participants on the Internet between the 11th and 20th of October 2018 and lasted approximately 15 min . Respondents gave their implicit and anonymous consent by answering the questionnaire. The survey was approved by the Ethics Committee of Université Laval . --- Measurement The survey questionnaire was developed for the purposes of the present study. It was developed following Ajzen's guidelines for developing a TPB questionnaire [29] and included the behavioural and control beliefs identified in a preliminary elicitation study [32]. Briefly, four semi-structured focus groups, each comprising seven French-speaking adults, took place to identify behavioural beliefs, normative beliefs and control beliefs towards a hypothetical participation in the NutriQuébec project. The participants included in the focus groups were recruited through non-profit organizations known to serve populations living in deprived sectors of Québec City. Thereafter, two coders conducted an independent content analysis to classify the respondent's answers in themes and to identify salient beliefs. The final classification of the beliefs was determined by consensus between the two coders. A third coder was involved when the two coders disagreed on some classifications. Since the aim of the present study was to develop strategies to optimize the recruitment and retention of individuals with a low SES in the NutriQuébec project, only beliefs that were the most relevant in the context of this project were included in the survey questionnaire. For example, although no or limited access to Internet was identified as a salient barrier to participation, this specific belief was not assessed in the survey because providing alternative methods such as sending a paper-and-pencil questionnaire by postal mail or providing direct support for Internet access was not considered in the NutriQuébec project because of feasibility issues. Similarly, factors that were out of the research team's control or that were mentioned in only one out of the four focus groups were not included in the survey questionnaire. Finally, although budget constraints hinder the research team from offering monetary incentives or gift cards to participants, this was assessed anyways in order to grasp interest in participation if no incentive was offered. Before launching the survey, the questionnaire was evaluated by six experts in the fields of behaviour change, health communication, nutrition, and epidemiology to validate the clarity and the intelligibility of the questions. Intention was assessed using three questions with the following items: 1) "I intend to participate in the NutriQuébec project", 2) The chances that I participate in the NutriQuébec project are … and, 3) I will participate in the NutriQuébec project. The answer choices varied from very unlikely to very likely and from very low to very high. Attitude was assessed using three questions : For me, participating in the NutriQuébec project would be … 1) very unpleasant/very pleasant, 2) very useless/very useful and, 3) very unsatisfying/very satisfying. Behavioural beliefs were assessed using six questions. Injunctive norm was assessed using two questions with the following items: 1) The most important people to me would think that I should participate in the NutriQuébec project and 2) If I were to participate in the NutriQuébec project, most people who are important to me would … strongly disagree/strongly agree. Descriptive norm was assessed using one question: Many people I know may be interested in participating in the Nutri-Québec project. Subjective norm represented the composite mean score of these three items and the Cronbach alpha was 0.66. Normative beliefs were not assessed in the present study questionnaire because no modal normative beliefs were identified during the preliminary elicitation study. PBC was assessed using three questions: 1) I feel that I am capable of participating in the NutriQuébec project, 2) I am confident that I can overcome any obstacles that may prevent me from participating in the NutriQuébec project and, 3) For me, participating in the NutriQuébec project would be … very difficult/very easy . Control beliefs were assessed using five questions . All psychosocial variables were measured using answer choices on five-point Likert or semantic scales. Participants also answered questions pertaining to their sociodemographic and socioeconomic position , Internet access at home as well as perceived computer skills. Perceived computer skills were assessed on a five-point Likert scale using the following question: How would you rate your ability to browse the Internet? --- Statistical analysis Sample size estimations were based on a study by Rashidian et al., who determined the number of participants to conduct sufficiently powered TPB studies [35]. Continuous variables are described as means and standard deviations while categorical variables are described as proportions. Data were analysed using a stepwise approach. First, multivariate linear regression models were used to identify how the three TPB constructs were associated with intention to participate in NutriQuébec, as suggested by Fishbein and Yzer [36]. We then examined, using multivariate models, associations between behavioural and control beliefs and their associated TPB constructs. This analysis was restricted to the TPB constructs that showed significant associations with intention, as identified in the first step. In all univariate and multivariate analyses, effect sizes are reported as standardized betas . Finally, logistic regression analyses were used to identify the behavioural and control beliefs that showed the strongest associations with intention to participate in NutriQuébec project. In this analysis, odds ratios reflected the likelihood of having a positive intention to participate, using negative intention as a reference . For that purpose, intention score was dichotomized with mean scores > 3 representing positive intention and mean scores ≤3 representing neutral or negative intention. TPB constructs and behavioural and control beliefs were treated as continuous variables in all analyses. All models were adjusted for sex, age, perceived ability to browse the Internet and for previous participation in studies on lifestyle habits conducted on the Internet. SAS Studio was used for all analyses and p-values below 0.05 were set to indicate the level of statistical significance. --- Results --- Participants' characteristics Sample size estimations determined that 148 participants were minimally needed to conduct the study. The sample comprised 184 women and 141 men with a mean age of 57.6 years . Sociodemographic and socioeconomic characteristics of the participants are presented in Table 1. The majority of participants had a high school degree as the highest education level attained , reported being moderately competent, very competent or expert in browsing the Internet , and had access to Internet at home . --- Linear regression analysis linking constructs with intention The multivariable linear regression analysis revealed that attitude and PBC were significantly associated with intention score, explaining 67% of its variance. Subjective norm was not associated with intention to participate in the NutriQuébec project . Similar results were obtained among men and women when analyzed separately . --- Linear regression analysis linking behavioural and control beliefs with corresponding constructs Table 2 shows the associations between respondents' behavioural and control beliefs and attitude and PBC respectively. The behavioural beliefs that were significantly associated with attitude in multivariate analyses were: 1) contributing to improving collective health , 2) having the opportunity to improve one's lifestyle habits , and 3) the fact that completing the survey questionnaires would be too time-consuming . The control beliefs that were significantly associated with PBC were: 1) receiving a personalized brief health assessment , 2) the use of simple questions , 3) participating in the research project even without financial incentives , and 4) participating in the research project even if the completion of the questionnaires would take two hours . --- Logistic regression analysis of intention to participate in the NutriQuébec project Figure 2 shows the results of the logistic regression analysis aimed at identifying beliefs that are associated with intention to participate in the NutriQuébec project. This analysis showed that participants who scored favorably for behavioural and control beliefs associated with attitude and PBC respectively also expressed a greater likelihood to participate in NutriQuébec than participants with negative scores for behavioural and control beliefs. --- Discussion NutriQuébec is a Web-based prospective study on diet and health among adults from the Province of Québec, Canada. The objective of this study was to examine the determinants of intention and its associated beliefs towards participation in the NutriQuébec project, targeting hard-to-reach individuals with a low SES. The results showed that attitude and PBC were both associated with potential participation in the NutriQuébec project and highlighted some key beliefs that should be considered to maximize recruitment and retention of individuals with a low SES. These study results are of most relevance to the NutriQuébec project. These findings could also be of interest to other prospective Web-based studies wanting to optimize recruitment and retention strategies among individuals with a low SES, although not being necessarily generalizable to all other Web-based studies because of the specific elements of the NutriQuébec project. Results suggest that favouring a positive attitude and a high PBC towards participation will be essential, whereas developing messages around some form of social *p-values and 95%Cl were found using linear regression models approval is unlikely to facilitate recruitment of individuals with a low SES. This is consistent with the results from our preliminary elicitation study, in which no salient normative beliefs clearly emerged towards potential participation in the NutriQuébec project among adults living in deprived urban areas [32]. A possible reason why subjective norm does not result in a significant determinant of intention could be the fact that the behaviour, participating in the NutriQuébec project, does not directly impact a person's environment or significant others. Similarly, participants in a study evaluating the intention to consult a blog delivered by a registered dietitian to improve their dietary habits reported that this action did not require the approval of others, since it was considered rather personal [37]. Our results are, however, at odds with data from previous studies on this topic. The study by Farmer et al. [38], which examined the TPB determinants of intention to participate in a medical research project among low SES and African American women, showed that attitude, PBC and perceived social norms were all associated with intention. However, it is noteworthy that the social norms related themes were trust in researchers and negative perceptions about the behaviour of researchers rather than focussing on others' approval/ disapproval [38]. Moreover, this study was not about participation in Web-based surveys. The study by Heerwegh et al. [27] also reported that positive attitudes, a higher degree of PBC and a positive subjective norm were all associated with a higher intention to participate in a Web-based survey among the general population. Similarly, Bosnjak et al. [28] observed that PBC best predicted intention to participate in a Web-based survey among undergraduate students, followed by attitude and subjective norm. Differences in results between our and previous study results may be explained to a large extent by the nature of the study populations with regards to SES. To our knowledge, the present study is the first to identify the determinants of intention to participate in a Web-based study on diet and health among individuals with a low SES specifically. Discrepancies between results also highlight a basic premise of the reasoned action approach : beliefs and determinants of a behaviour are highly context-dependant and should always be assessed when attempting to intervene in a target population [39]. Nonetheless, results seem to be coherent with the fact that participation in a study relies mostly on attitude and PBC. The positive behavioural beliefs that were significantly associated with a positive attitude and intention towards participation in the Webbased NutriQuébec project pertained to the potential Fig. 2 Beliefs associated with positive intention towards participating in the Web-based NutriQuébec project contribution to improving collective health and one's lifestyle habits. Altruistic motivation to participate in research projects has been reported previously [16,38,40,41]. For instance, African American and low SES women mentioned in focus groups that they would participate in a research project if it could possibly benefit others in the future [38]. Another study on the motives towards participation in a Web-based prospective study reported that the majority of participants took part in the research project to contribute to advancing public health research [16]. Contributing to improving the population's health and the environment was also identified as benefits to participating in a prospective cohort study [41] as well as in a study regarding the creation of a research database comprising personal, clinical and genetic information [40]. Interestingly, the second positive behavioural belief associated with participation in the NutriQuébec project pertained to the opportunity to improve one's health. This is in line with previous studies on altruism, which highlighted that pure altruism is not always observed and that individuals expect some form of reward in exchange for their time and participation [38,42]. This suggests that framing participation in the Web-based NutriQuébec project as an altruistic act may be a promising strategy to recruit individuals with a low SES. However, persuasive messages may also need to highlight the potential opportunity to learn more about one's health and even improve it. The fact that obtaining a personalized brief health assessment was among the significant discriminant facilitating factors further supports this assertion. The recruitment and probably the retention of participants with a low SES in the Nutri-Québec project are therefore likely to be facilitated by providing a brief health assessment as a participation reward. Similar findings were reported by Yamamoto et al., where participants with a high level of motivation to participate in a study mentioned that having access to their own results was a motivation factor [41]. Nevertheless, providing individualized feedback on diet and health raises concerns in the context of conducting a prospective study aimed at examining the associations between the population's health and the impact of policies on health since providing a health assessment might be considered as an intervention by itself [43]. Thus, providing feedback needs to be balanced between participation reward and satisfaction and behaviour change motivation to limit potential bias in estimations. Strategies to control for potential impacts of the feedback mechanisms on participants' behaviours over time may also need to be implemented to ensure that they can be captured and adjusted for in the analyses. The burdensomeness of taking time to fill out numerous questionnaires was a negative behavioural belief associated with participating in the NutriQuébec project. Similarly, it was observed from a longitudinal study with weekly Web surveys over 2.5 years that some participants found the long-term and repetitive nature of surveys tedious [44]. The time burden associated with participation of low SES or minority populations in studies has also been documented elsewhere [22,23,45], suggesting that the idea of being considerably committed to a study discourages participants and may increase attrition over time. Considering the fact that prospective studies necessarily involve repeated observations/measures over long periods of time, strategies in data collection must be adopted to make sure that participants perceive more benefits than disadvantages. Retention strategies in longitudinal studies include the reduction of participant burden [46] and taking into account participant suggestions regarding data collection [47]. Participants who declared that they would participate in the research project even in the absence of monetary incentives expressed a higher degree of PBC and intention. This suggests that providing a financial incentive to increase participation in a Web-based longitudinal study may not be necessary among individuals with low SES. This is consistent with findings by Edwards et al., which showed no evidence that a monetary incentive encouraged participants to complete Webbased surveys [48]. Instead, they reported that offering a non-monetary incentive increased the odds of completing a Web-based survey by two-folds [48]. It should be noted that findings from this Cochrane Review were not necessarily drawn from studies conducted only among SES populations. This is also consistent with our elicitation study, in which all focus groups expressed an interest in non-monetary incentives, like receiving a health assessment [32]. Likewise, results from the present study showed that receiving a personalized brief health assessment was associated with high PBC and high intention to participate in the NutriQuébec project. On the other hand, other studies have shown that providing a financial incentive was effective to encourage low-income, unemployed or hard-to-reach individuals to participate in a study [49][50][51]. Yu et al. reported that the use of a modest monetary incentive in a longitudinal study increased the number of returned surveys [52]. Taken together, these results suggest that the effect of a monetary incentive on recruitment and retention of participants remains uncertain, particularly for long surveys, and more studies on this topic are needed to clarify the impact of such an approach on participation in Webbased research projects. Studies have often reported an inverse association between the length of the questionnaires and response rate [48,[53][54][55]. Inversely, results from another study showed that longer questionnaires were associated with higher participation rates, which could possibly be explained by the fact that a greater involvement in the study seemed to increase interest in research participation [56]. Participation in epidemiological studies has decreased in the past decades [46], emphasizing the importance of identifying underlying factors, including questionnaire length. Considering the fact that the NutriQuébec project requires completing questionnaires once a year, it was important to know if the length of these questionnaires would be a barrier to participate in the study for individuals with a low SES. Our results suggest that participants who would participate in the research project even if the questionnaires took two hours to complete had a high degree of PBC and high intention. Allowing participants to complete questionnaires over an extended period of time rather than during the predefined one-month window of time may decrease the perception that participation is burdensome and increase self-efficacy toward this behaviour. However, at study onset, it was decided not to modify the period to fill out all questionnaires to minimize time disparity in the measurement of the various health behaviours. The use of simple questions was significantly associated with high PBC and high intention towards participation in the NutriQuébec project. This result highlights the significant need to address literacy issues to recruit and retain individuals with a low SES in prospective research projects. Consistent with this, a study reported that individuals with low literacy were more likely to prefer simple sentences when presented with six different descriptions for each predetermined research term [57]. Low literacy is more prevalent among adults with a low SES. Indeed, among the Québec adults who do not have a high school diploma, unemployed and low literacy persons are overrepresented [58]. Additionally, a study reported that adults with low health literacy and numeracy were significantly less interested in participating in research projects, most probably because of the difficulties associated with understanding consent forms and perceived risks pertaining to the project as well as the skills needed to complete survey questionnaires [59]. To help recruit individuals with a low SES among the Québec population, efforts need to be made to simplify the questionnaires and test them for clarity within low SES groups. Efforts will also be made to present and explain the study in simple terms on the NutriQuébec website. --- Strengths and limitations As indicated above, this is the first study, to our knowledge, that examined determinants of intention of participating in a Web-based prospective cohort study as well as the influence of behavioural and control beliefs on this intention among a sample of adults with a low SES. The TPB was used as a validated framework for the basis of this study, which is another strength because of its strong predictive capacity. Also, participants were recruited from sixteen different administrative regions in the Province of Québec, Canada, which suggests a good representation of individuals with a low SES across the Province. On the other hand, this study was only conducted in French, which may not represent the beliefs of English-speaking Quebecers, as well as those of immigrants or Indigenous people who cannot complete the survey questionnaire in French. Findings may also not be representative of all low SES individuals in Québec considering that the vast majority of participants reported having access to Internet and being competent using the Internet, which is most likely related to recruitment via a Web panel of a polling firm. Additionally, given the relatively low response rate, a selection bias cannot be ruled out. Indeed, it is possible that the individuals who participated in the study had a greater interest in nutrition and therefore were more prone to having a higher intention of participating in the NutriQuébec project as well as to perceiving more advantages and fewer barriers. Findings may also not be generalizable to all prospective Web-based studies considering the specific elements of the NutriQuébec project. Lastly, the cross-sectional nature of the study is also a limitation. Future studies would benefit from identifying whether intention leads to behaviour within this population. --- Conclusions This study examined for the first time the intention of participating in a Web-based prospective cohort study among adults with a low SES, as well as the influence of behavioural and control beliefs on intention. Using the TPB, we observed that favouring a positive attitude and a high PBC towards participation in a Web-based project are likely to be key factors facilitating recruitment among adults with a low SES. Furthermore, altruism, improving lifestyle habits and receiving a health assessment were significant behavioural and control beliefs that should be leveraged in the recruitment and retention strategies to encourage participation in the NutriQuébec project. Questionnaires should also be as simple and short as possible to favour participation of adults with a low SES. These results are of importance for future Web-based prospective studies in order to adapt recruitment and retention strategies to help capture data from all groups of the population, particularly those that are more socially disadvantaged. --- --- Supplementary information Supplementary information accompanies this paper at https://doi.org/10. 1186/s12889-020-08467-1. Additional file 1: Supplementary File 1. The TPB Survey Questionnaire. Abbreviations PBC: Perceived behavioural control; SES: Socioeconomic status; TPB: Theory of planned behaviour Authors' contributions MC and SH wrote a first draft of this paper and performed the analysis with ABG. SD, SL, BL and ABG designed the study. AL and CL coordinated the study. All authors have reviewed and accepted the final version of the manuscript. --- Funding Financial support for this study was provided by the FRQS Réseau de recherche en santé cardiométabolique, diabète et obésité. The funder played no role in research design, data collection, data analysis, manuscript write-up or decision to publish. --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Prospective cohort studies may support public health efforts in reducing health inequalities. However, individuals with a low socioeconomic status (SES) are generally underrepresented in health research. This study aimed to examine the intention and determinants of intention of individuals with a low SES towards participation in a Web-based prospective project on nutrition and health (NutriQuébec) in order to develop recruitment and retention strategies. Methods: A cross-sectional survey based on the Theory of planned behaviour was conducted in the Province of Québec, Canada. Low SES individuals (high school or less and annual household income < $55,000 CAN) were recruited through a Web panel of a polling firm to assess intention, attitude, subjective norm and perceived behavioural control (PBC) towards participation in the NutriQuébec project. Linear regression and logistic regression analyses were conducted.

Much has been learnt in the last twenty years about how human beings actually learn. Preceding this learning are long-standing debates which feature, on the one hand, behaviourists who believe that learning happens as a response to external stimuli, and, on the other, cognitivists and constructivists who believe that human beings mentally process and work with the stimuli to which they are exposed in entirely distinct and individual ways . New understandings of the relationship of the individual brain to the social context in which an individual finds him/herself/themselves have fundamentally weakened the polarized and dichotomized nature of that old debate. This new knowledge, I suggest here, brings an urgency to the educational discussion of inequality. It by no means takes away the material significance of disadvantages such as poverty but it calls, in addressing it, for far greater sophistication in the management of inequality. The circumstances of COVID-19 have accelerated this urgency. Every day, since about February 2020, when the first of the global lockdowns began in Wuhan, China and into the perhaps not-so-foreseeable future, teachers, parents, caregivers, and children themselves have been working out how to manage the processes of learning. In deep experiential ways, the question of learning has become more than a question of theory and opinion. People have had to think about how to do it efficaciously and meaningfully. --- COVID-19's reach The world has never before experienced anything like COVID-19. We have experienced pandemics before: The devastation of the Spanish Flu of 1918, which caused the deaths of approximately 50 million people, is an example. The world, however, has not previously had to respond in conditions of hyper-connectedness. It took several months for the Spanish Flu to work its way around the world. Globalization, and in this particular case of COVID-19, where air-travel is the medium, has dramatically compressed, to use Held, McGrew, Goldblatt, and Perraton's famous phrase, "time-space". In a matter of weeks from December 2019, immense controls and safeguards notwithstanding, the world went from reports of clusters of cases in Wuhan to 5,710,836 infections and 352,869 deaths globally by 27 May 2020 . On 11 March 2020, the World Health Organization , based on incidences which had ballooned to 118,000 cases in over 110 countries around the world, declared COVID-19 a pandemic. The Director-General of WHO, Tedros Adhanom Ghebreyesus, explained that what the world was dealing with was "… not just a public health crisis. It is a crisis that will touch every sector" . A sector which, predictably, has been affected disastrously is education. Writing for the World Bank, Jaime Saavedra , explained: "As of March 28, 2020, the COVID-19 pandemic is causing more than 1.6 billion children and youth to be out of school in 161 countries. This is close to 80% of the world's enrolled students". UNESCO's estimates of the number affected by 27 May 2020 were somewhat lower but still alarming-1,190, 287, 189. One hundred and fifty countries had closed their systems. Collating the numbers accurately is difficult. The picture, the point cannot be escaped, however it is constructed, is dire. Well over two-thirds of the world's children have been affected. In most countries schools have been shut down for several weeks. At the time of writing, schools have been shut for 61 days in South Africa. Saavedra explains the effects of school systems shutting down: "We were already experiencing a global learning crisis, as many students were in school, but were not learning the fundamental skills needed for life". The World Bank's Learning Poverty indicator-the percent of children who cannot read and understand at age 10-stood at 53% of children in low-and middle-income countries, before the outbreak started. "This pandemic has the potential to worsen these outcomes even more if we do not act fast" . Colleagues and I, writing in The Conversation, painted a picture of these worsening outcomes for a relatively well-organized system such as South Africa's. Extrapolating from the data we collected for the 2015 Third International Mathematics and Science Study for South Africa, where we applied "the learning curve scenario methodology developed by the World Bank to the South African context to illustrate the patterns of expected learning losses over the next few months due to school closures and disruptions" . Our estimates were that learning losses amongst poor children would lead to catastrophic results. We said: "More learners from no-fee schools will fall below the 'learning poor' score of 300" . --- Responses to COVID-19 In response to these developments, systems, schools and educational authorities have moved quickly. A rapid-response survey conducted by Reimers and Schleicher of 98 countries around the world found that school systems were teaching online using a variety of platforms, broadcasting lessons on television and radio and putting in place innovations such as socially distancing proof hubs and centres. Working with this information, Reimers and Schleicher developed a guide for how systems could respond. What is clear is that everywhere in the world both at system-wide levels and right down to households, interventions are underway to sustain and support learning. In the South African setting, the Department of Basic Education announced at the start of the national lockdown proclaimed by the government that: In accordance with the pronouncement by the President on 15 March 2020, schools will be closed from 18 March and will reopen on 14 April 2020. This decision has been informed by the warnings provided by the National Institute of Communicable Diseases and World Health Organization who have highlighted the alarming increase of infections within the country over a three-day period…Provincial Education Departments, districts and schools are advised to take advantage of this time and are encouraged to utilise the time effectively by ensuring that learners participate in established stimulating programmes such as the Read to Lead programme, maths buddies, constructive holiday assignments, etc., through the supervision and guidance of parents and the broader community whilst learners are at home. This will be supported through the provisioning of workbooks, worksheets, readers, etc. Innovative examples shared by participant countries to the Reimers and Schleicher survey include separate portals for teachers, learners, and parents in Israel, virtual meeting places in Italy, and many other initiatives. In countries such as the Netherlands and Portugal, governments have made grants available for poor parents to obtain the devices they need for accessing online services. In schools everywhere, teachers are developing innovations 1 3 using a wide range of supplementary pedagogies. In the higher education sector in South Africa, the Ministry of Higher Education and Science and Technology has developed a global positioning system intervention which is in the process of locating almost every single registered student in the system and every public education site-universities, colleges, libraries, post-offices and museums. Mapping the former on the latter, for the purposes of facilitating access of students to their most conveniently located connectivity resources, it has offered universities and colleges a mechanism for dealing with the questions of learning opportunity. --- Cost of COVID-19 The Reimers and Schleicher study and a briefing by the International Labour Organization provide, also, a sense of what the costs of the pandemic are and particularly what is not being done in many parts of the world. Reimers and Schleicher report , and clearly more detail is required, that "hen asked what has the government or network of schools done to support the ongoing academic instruction of students, a large percentage indicate 'nothing'". The possibility exists, and it is suggested by informal and unofficial reports of the large numbers of children playing in the streets during what would have been school time in the cities of South Africa, that little or no learning is happening in large parts of the world. The ILO gives a sense of the damage that is being felt: While solutions to the disruption have been innovative and responsive, the reality remains that some schools and regions are better positioned than others to take advantage of resources, technological infrastructure and the technology market to respond to the crisis in more effective and comprehensive ways. The emphasis on virtual learning can exacerbate existing inequalities in education, particularly in developing contexts, marginalized communities and rural settings, where access to technology and reliable internet connections may be limited. Even within schools, inequalities such as those related to persons with disabilities or family income can hinder access to distance learning. Distance learning does not allow schools and teachers to carry out their important role in the socialization of learners and in the provision of social services, such as, for example, school meal programmes. Kingwell , writing from the perspective of a privileged university in North America, emphasizes the point: "Among other things, the massive and sudden shift in teaching at all levels exposes social and economic faultiness that predate the current pandemic" . The problem which is being focused on in these analyses is access to technology. The ILO, representing this line of critique, points out that: "…In many countries in South-West Asia and sub-Saharan Africa, only about 20 percent of households have internet connectivity, and few have personal computers" . "… What we need to avoid-or minimize as much as possible", says Kingwell , "is for those differences in opportunities to expand and cause the crisis to have an even larger negative effect on poor children's learning". --- Towards a larger view of inequality As I have said above, the symptoms highlighted by current literature on COVID-19 quite correctly focus on the situation of the demographically poor in the world and to improving their online access. I would like to argue, however, that the pandemic presents the world with a clear picture of the inherent blind spots of mass education and the complications associated with the principle of universal education upon which it is constructed. It is this to which I now turn. The argument I make in this contribution is that our defining blind spot emanates from our homogenization of the learning subject and his/her/their identity. Even as the world's educational policy makers have shifted towards learning theories such as cognitivism and constructivism, they have tended to use a homogenized learner as their subject for analyses. Where they have brought inequality into their analyses, they have done so on the basis of a normativizing middle-class sensibility-what poor learners ought to have access to. Poor and disadvantaged learners are constructed in these framings not only in deficit terms in relation to middle-class norms and standards but their material realities are compressed into stereotyped identities framed by singular, fixed and essentialized understandings of race, class, gender, ethnic background, language, sexual origin, ability, religion, and many other forms of difference. The point I am seeking to make here is that the learning subject in his/her/their intersectional complexities is not visible in the developments that are in play in the new context of the pandemic. I concede, as I have said above, there are understandable reasons for the directions that governments and systems are taking to deal with the crisis. The logistical challenge of managing learner and student progression in the world's educational systems is a planning nightmare. But the complexity of what is actually taking place in the process is not being considered at all. What is that complexity? It is that the construction of a homogenized learner, either in his/her/their identity of privilege or disadvantage, misrecognizes the actual politics of the learning experience and, so, the individual learner. That politics would need to proceed from the premise, as Nikolas Rose says of the challenges of working in the cognate space of psychiatry, that young people inhabit a world in which they are learning, an ecology which is enormously messy, imbricated, overlapping and continuous and discontinuous in both material and psychological ways that matter. This world includes "homes, shops, buildings, roads, countrysideintersubjective-communities of support or exclusion, discrimination, racisms, exposure to actual or potential dangers and hazards from others-social-forms of work, experi-ences… saturated with public and private meanings" . But it is about more than their external environments. It is also, fundamentally, about their biological distinctiveness. It is about, beyond the physicality of their material worlds, living in bodies with brains, which are, in every single instance, completely different. These differences of the body and the brain and particularly the material differences of "male" brains, "female" brains, "autistic" brains, "artistic" brains, "scientific" brains, "left-hemisphere dominant" brains, and much more, in a plurality of different kinds of bodies, are the subject of intense debate. Jantz , for example makes the claim that "the differences between male and female brains in these areas show up all over the world, but scientists also have discovered exceptions to every so-called gender rule". The gender discussion, as one facet of the body and brain discussion, is particularly controversial with significant theorists such as Mikkola arguing that "various critiques of the sex/gender distinction have called into question the viability of the category women". However, one wishes to resolve these questions of bodies and the brains they contain, we have to proceed from an acknowledgement that our scientific understanding of what is happening in the brain is a young and largely exploratory field. Writing recently on their attempts to image the circuitry of the brain, Wang et al. make the point that "…most previous large-scale circuit studies assumed that local circuit properties are the same across brain regions. Since different brain regions have distinct microscale and macroscale properties, assuming identical parameters across brain regions is overly simplistic". Brains work differently. Rose, Meyer, Strangman, and Rappolt emphasize that "in recent years, scientists have made unprecedented progress toward unlocking the secrets of how our brains learn, driven in part by remarkable new technologies and techniques for imaging the brain's activity". They emphasize that "although all brains share… general characteristic, individual brains differ substantially-a point that bears critical implications for teaching. Understanding the specialized functions of the recognition, strategic, and affective networks can help us appreciate the unique strengths and weaknesses of individual students". It is in coming to terms with the idea of every child's "unique strengths and weaknesses" that the idea of the sociologically and psychologically normative learner presents to us an important challenge. We have, beyond our deeply important sociological characterizations of the children in our classrooms, children who are bearers of immense complexities. Rose et al. describe these as "strengths and weaknesses". I would prefer to use a less judgemental frame and say, perhaps no less problematically, "differences". In working with this challenge of difference, obvious victims are learners with disabilities. An email message distributed by Pamela Joy Lumagabas, from inside a consultancy called Cardinal Learning of California, says of the COVID-19 situation for learners in the American context that "tudents with learning disabilities are being abandoned by the education system. Their normal cadre of specialists that have helped them in the past are no longer able to tend to their needs". The question of learners with disabilities is acknowledged in the ILO and Reimers and Schleicher analyses. But the issue is more complex. It rests on the question of recognition. Who is being recognized in describing the crisis? I suggest that what we are seeing in the crisis are predictable casualties and, critically, human subjects that receive no recognition. It is important to attempt an unpacking of who the human beings are within our midst who do not easily come to our minds. They are numerous. They begin, of course, with the normalized, but no less therefore worthy of our attention, marginalized layers of people of colour, women, people with delegitimized sexual preferences, poor people, linguistic marginal, differently abled and so on. There are, however, amongst us many less obvious mis-and unrecognized subjects. Rose et al. are immensely insightful for making the point that even so-called 'disability' is susceptible to misrecognition. They explain that "ew understanding about the distributed nature of neural processing shows that abilities in many domains fall along a very large number of continua. Further, the importance of a particular strength or weakness depends on what is being asked of the learner. This is why, for example, a youngster with perfect pitch who has difficulty recognizing letters is seen as disabled, but a child who is tone deaf but can read words is easily not" . Much less obvious are learners from all kinds of contexts, whether they are, in the taken-for-granted sub-categories of the dominant ways in which we have come to classify our human landscape, rich-poor, black-white and male-female, who, and this is the issue for understanding inequality, actually, all, learn differently. They learn mathematics in distinct ways. They learn languages in different and very individualized ways. We have, in our failure to recognize the different needs and requirements of learners, subtle and yet deeply injurious inequalities. They are no less damaging than the grand factors of race, class and gender. When a child struggles to process in his/her/their executive functioning how the logic of a sentence can be ordered, or how a calculation comes to produce a very specific outcome, or how a symbol might precipitate a particular association, a facilitating teacher needs to understand that a norm-structured model of how that child should learn constitutes a potential injustice. And so, when the guidelines for helping schools and systems deal with the COVID-19 crisis specify what needs to be done, and again, all the caveats I put on the table earlier continue to be pertinent, the overwhelming narratives are about "salvaging the year" and "completing the curriculum". Built into this narrative is misrecognition of the task that a modern, equality-conscious and difference-conscious society has before it. That task is recognizing the wonder of the extraordinary complexity each child presents to us. If we don't, we make the error of privileging gross versus subtle but no less insidious inequalities within our midst. --- Innovating to mitigate inequality As the digital imperative looms large in our lives, and as we come to acknowledge the inescapable reality that our teaching and learning strategies must embrace these new online affordances available to us , taking us towards what commentators such as Olivier describe as "customised blended learning", we have to remain mindful of what our new learning about learning is telling us. Assimilating that learning in structured and comprehensive ways is clearly the next task to be focused on in the formal spaces of teacher professional education and in the less formal socialization cultures of families and communities around the world. In some ways, and this awaits documentation, ahead of that next step, COVID-19 has brought teachers, parents and caregivers to the need for new approaches to learning. Reimers and Schleicher share the testimony of Hungarian respondents to their survey: "Teaching has been shifted to the digital. The government tries to give support for this to schools/teachers but most of the initiatives seem to be bottom-up. One witnesses a remarkable dynamism and activity in many schools [my emphasis]". It is important that we are able to record and make sense of this dynamism. Anecdotal reports from many quarters speak of teachers, parents and caregivers working harder than they ever have in their lives. These reports also speak of practical and pedagogical insights to which people are coming. These insights are beyond the digital. Within them are emerging practices which respond to practical anxieties-such as "salvaging" the school year. But there is also a sense of defending and cultivating the virtues of learning. The big and perhaps too difficult a prize to present is that of individualized learning. Our new politics of learning tells us clearly that every child will learn differently. Structuring learning programmes for each individual is clearly beyond our reach. In practice, personalized learning is not within our resource, technical, social or scientific capability. It will not, therefore, in any likelihood happen. But we have to understand that it is an important social issue, as yet inadequately articulated, for our discussion going forwards-a matter of cognitive justice. Rose et al. helpfully point to a way forward: Because smooth functioning recognition networks take advantage of both top-down and bottom-up processes , teaching to both processes rather than focusing exclusively on one or the other is the wisest choice. A positive example is the recent truce in the "phonics wars". Most programs have now adopted a form of reading instruction that incorporates both the top-down whole language method and bottom-up phonics. The balanced approach is consistent with the way the learning brain works. --- Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Crain Soudien is the CEO of the Human Sciences Research Council and a Deputy Vice-Chancellor at the University of Cape Town. He is a joint professor in Education and African Studies at the same university. He has published over 210 articles, reviews, reports, and book chapters in the areas of social diference, culture, education policy, comparative education, educational change, public history and popular culture. He is the author of three books, Youth Identity in Contemporary South Africa: Race, Culture and

The purpose of this Viewpoint is to argue for an enlarged understanding and approach to the question of inequality and education. While much of the current discussion is correctly focused on learners' material realities and how COVID-19 is exacerbating those inequalities, largely overlooked is how the core activity of the education experience-learning-is managed, simultaneously, at the macro-level of the state, and the micro-levels of the individual learner. We now know how complex learning is. Our new knowledge is informed by new understandings of the relationship between the biomedical and the social. It is suggested that what is necessary in this crisis and going into the future, is deconstructing and making sense of the complexities of these realities for the quality of the learning experience.Inequality • Learning • Quality • Crisis • Pandemic • Learning sciences • Future of education The purpose of this brief intervention is to propose a restatement and a repositioning of the question of inequality in education as it is playing itself out in the context of the global upheavals caused by COVID-19. Much of the current discussion of inequality is correctly focused on learners' material realities and how the pandemic exacerbates those inequalities. What is largely overlooked, and this is understandable given the enormity of the task facing governments of holding the basics of their educational systems intact and functional, is how the core activity of the education experience-learning-is managed, simultaneously, at the macro-level of the state, and the micro-levels of the individual learner. I suggest that what is necessary in this crisis and going into the future, is deconstructing and making sense of the complexities of these realities for the quality of the learning experience (and, it needs to be said, the teaching experience).

INTRODUCTION Refugees face many difficulties in their lives, and settling in a new and markedly different environment can be an added difficulty for many of them . These difficulties may lead to poor 'psychosocial adjustment' and emotional problems ) in refugees, who often embody significantly higher mental health problems than other populations in general . As elsewhere, refugees in Australia have lower levels of personal well-being than other migrant groups . This is particularly so for newly arrived refugees, and more so for women, who are often culturally displaced, socially isolated and have ambivalent feelings about their future . This acculturative stress is likely to result in depression among refugees . For any individual, having to relocate to another social setting necessitates extensive adjustment, which often leads to changes in health status as well as disruptions to family connection and social network . This is more marked among refugees who have experienced violence and civil conflict in their homeland . For many refugees, resettlement can be very daunting. It has been suggested that the resettlement process that refugees go through can have more negative impact on health and well-being than their pre-migration situations . doi: 10.1093/heapro/dav015 Nevertheless, there are factors which have helped to protect refugees during their settlement processes, in particular, social support from peers and their own ability to cope . According to Mulvaney-Day et al. , social support provided by 'unrelated, close friends' has shown a positive influence on the physical and mental health of refugees. Social support can help to alleviate some of the difficulties associated with resettlement in a new environment . We contend that one aspect of social support for refugees is being part of a peer support group. In this paper, we discuss the experiences of refugee women who participated in the peer support programme for newly arrived refugee women in Melbourne, Australia. Our project adopted a two-pronged approach to establishing peer support networks among refugee women from similar communities. Peer support training enabled the participants to meet, discuss issues and consequently establish communicative relationships within the peer group. Additionally, the women were given access to a free mobile phone. Research has shown that mobile phone access can act as a health promotion tool . In this study, participants were provided with a free mobile phone and free unlimited calls within the peer support group numbers, and to limited set of local and overseas numbers, for a 12-month period, to augment the peer group relationships, as well as relationships with a small number of people and institutions external to the peer group. Peer support group as social support and health enhancing strategy: theoretical framework In this article, peer support is perceived as a subset of social support in which the relationships are formed between individuals who are similar to each other. Peer support has received much attention within the mental health area . It has been defined as 'social emotional support, frequently coupled with instrumental support, that is mutually offered or provided by persons having a mental health condition to others sharing a similar mental health condition to bring about a desired social or personal change' . This concept is clearly relevant to our project, which attempt to use peer support group to enhance the health and well-being of refugee women. In the case of the refugee situation, emotional, physical and tangible support which is offered by 'peers', who are also refugees, can lead to desired personal and social changes within their communities. Peer support embodies 'active ingredients' which enhance positive health and well-being among group members . Peer support groups which provide a channel for individuals to periodically meet to address commonly shared concerns and problems have resulted in social support among group members, which has, in turn, led to the improvement of quality of life of those involved . Within peer support groups, empathy, sharing, support and assistance are often offered . As such, feelings of social isolation can be overcome . Schutt and Rogers put it clearly that peer support 'provides resources for effective functioning and a foundation for coping with stress and loss'. Additionally, a peer support group has been seen as the principal ingredient of the empowerment process . Peer support programmes not only increase social support, they can also promote empowerment among group members . Peer support makes the most of the ability of peers to contribute to the situations and needs of others in the group as well as their potential for influential relationships with others . In our study, we based our research within the peer support framework discussed earlier. The peer support group training sessions and the provision of a free mobile phone offer a means through which meaningful empowerment processes could eventuate . Here, we emphasise the empowerment that become materialised at the individual level, and we refer to this as 'personal empowerment' . According to Chamberlin , this personal empowerment is 'a multi-dimensional concept' which embodies the feeling of being part of a group and promotes positive self and the conquering of personal difficulties. Within the refugee context, peer support could empower individuals to find ways to overcome difficulties in their new homeland. Additionally, we contend that participation in peer support group can be perceived as health-promoting behaviour. Within the health behaviour framework , it is assumed that by participating in peer support group, people will receive benefits of some kind. For example, participants may perceive that being a group member would assist them with difficulties in life. Additionally, it will entitle them to some support that will help them fight against isolation and difficulties in their everyday life. As such, participation in peer support group training can be seen as a health-promoting behaviour with the expectation that support from others may follow. --- Peer support group activities: our project The peer support group activities ran for 12 months. Different groups have different start times, but the whole programme started in 2010 and ended in 2012. Participants attended weekly peer support training sessions for the first 6 weeks and five bi-monthly sessions. Group composition and timings were guided by participant preference, resulting in 9 groups with 9-15 members. The women practised 'swapping time' where, for 3-5 min, they took turns in the roles of talker and listener. The themes for each session were selected using a strength-based, assets model designed to direct the women's attention to the positives in their lives . These themes included the following: something good, something new; goals and aspirations; educational successes; personal pride and other topics that were defined by circumstances of the time. The group sessions ended with a whole-group discussion during which each woman shared a thought, feeling or anecdote with the rest of the group. The importance of confidentiality was stressed to the participants from the start of the programme, and this helped to establish trust as an expected group norm. The women were presented with certificates of participation at the end of the fifth and the last session. In the third training session, each woman was given a mobile phone with the following unlimited free-call numbers on speed dial: • Intragroup numbers: peer support group members from the same community; • Landline numbers: home landline and four participantchosen Australian landline, or overseas numbers from selected countries and • Service numbers: telephone interpreter service , four participant-chosen service provider numbers and two members of the research team who facilitated the peer support groups . A special agreement was established with the phone service provider that enabled the free calls to be provided cheaply. The phone calls made by the women were recorded automatically in a call log that captured the time, duration and destination of the calls . Only outgoing calls could be logged as it was not possible to log incoming calls. The intragroup numbers linked people within their heritage culture. As the Australian landline and overseas numbers were selected by the participant, they were predominantly numbers of close friends or relatives of the participants and therefore classified as numbers associated with the participants' heritage culture. The third set of numbers provided the participants with links to the host culture. These were the TIS ; four selected service providers including schools, clinics and hospitals and the two researcher facilitators. It should be noted that there were some women who did not attend all the training sessions, and some who along the way stopped using their phones. However, no one actually gave the phone back and wanted to be taken out of the programme. In our qualitative component , we did include women who made very few calls compared with their colleagues. --- Methodology This paper is based on the qualitative component of our project that examines the roles of peer support and mobile phone-enhanced communication in the settlement experience of refugee women living in Melbourne, Australia. A full project has been reported elsewhere . Initially, potential participants were invited by the Afghan, Burmese and Sudanese community leaders to an information session where the study was explained, questions answered, and participant information sheets and informed consent forms, in both English and the community languages, distributed. A snowball sampling technique was also used, where the first group of participants invited people they had relationships with to join the programme . This recruitment process helped to elicit moral approval and practical assistance from heritage culture gatekeepers, husbands or adult children, who had the capacity to influence the women's participation. In our full study, 111 women were recruited; 44 from the South Sudanese, 31 from the Afghan and 36 from the Burmese communities. The mean length of stay in Australia are 2.88, 4, 4.19 and 6.81 years for the Burmese 1 , Burmese 2 , Afghan and Sudanese communities, respectively. Within the consent form were questions that asked participants for yes/no responses to questions requesting participation consent to an interview. Interviewees were selected from those responding 'yes' to an interview. Thus, the number of participants who took part in the study component on which this paper is based was not determined by saturation. All of these participants also agreed to being audio-taped. Where possible, women selected for interview were approached directly to invite participation. Where language was a barrier, participation was invited through the relevant interpreter. At the end of the programme, 29 participants were interviewed. Invitations to participate in an interview were based on the women's mean calls per week and mean call duration . Each cultural group was proportionally represented. Interviews were conducted by the second and third authors, took place in participants' homes, lasted 60-90 min and were recorded after participant consent. Apart from three participants who were proficient in English, all interviews were assisted by a professional interpreter. Questions explored the women's programme experiences, the changes in their lives and relationships and the significance of their call patterns. The data were analysed using thematic analysis . This method of data analysis aims to identify, analyse and report patterns or themes within qualitative data. Initially, we performed open coding where codes were first developed and named. Then, axial coding was applied which was used to develop the final themes within the data. This was done by reorganising the codes that we had developed, from the data during open coding, in new ways by making connections between categories and subcategories. This resulted in themes, which were used to explain the lived experiences of the participants. The emerging themes are presented in the Findings section. Three transcripts were initially coded by two authors who are qualitative researchers, and differences in coding discussed and resolved. Subsequently, for all other interview transcripts, uncertainty about assigning codes to specific pieces of text was resolved jointly by the two researchers. Ethics approval for the project was granted by the Faculty Human Ethics Committee, La Trobe University. In presenting the narratives of the women, we adopted the use of fictitious names in order to preserve their confidentiality. For ease of reading, we also minimally edited the verbatim quotes to make them more grammatically correct. --- Findings To most of the women in our study, participating in peer training sessions and having access to a mobile phone made a huge difference to their lives. There are several major themes that emerged from the study: creation of social networks, enhancement of well-being and provision of empowering experiences. --- Creation of social networks Social networks were created through the programme that was developed for our study. The peer support training sessions and the access to a mobile phone allowed the women more connections with others as well as strengthen their own personal/social networks. --- Cultivating new social network For most women, the programme provided an opportunity for them to meet other women in their community. Most often, however, social networks between the women were increased due to the effect of group sessions. Many women suggested that having only a mobile phone would not create the network and that it was only through group sessions that such networks developed. However, other women remarked on the benefit of both having access to a mobile phone and participating in peer group session trainings. Meeting others in a group setting and having their mobile numbers and a means to make connection enabled them to connect with others. If it wasn′t for this telephone I wouldn′t know because that person she doesn′t even know my other mobile number that I made at the group. So if it wasn′t this group I wouldn′t have met the person. Since the women had more opportunities to connect with others in the community, their lives were changed. For me, I can say there is a change in my life because I met other people that I don′t know before. . . I don′t talk to before [but] now they are part of our community and I get to know them better. Creating strong links within the networks The peer support programme and access to a free mobile phone also created stronger relationships among group members. We particularly noted this relationship, within the Sudanese community, between the older women and the young women who had no parents in Australia. Often, refugee children and young people have lost their parents through war and escape attempts. In these stronger relationships, the older women acted as a mother for these young women. It is because of this programme . . . we sort of become close . . . [We have become] close to these young woman already. And they are [treated as] our daughters. Some of them, they don′t have their mom here. So, we play their role now and we practice it a lot because of this. Social isolation is common among refugees, and some women claimed that they did not have any 'friends' prior to the programme, which helped to create a closer connection between the women in the community. For those who might have seen or known each other beforehand, the programme provided an opportunity for them to form a closer relationship. Thus, links between individuals as well as community became strengthened. Having access to a mobile phone and being connected to others in the community allowed the women to strengthen ties with members of their cultural community and participate more fully in it. This is an essential aspect of resettlement for many refugees, including the women in our study. Access to a mobile phone enabled the women to connect with family members who were left behind in their home country. This is crucial for refugees who feel a strong need to be in contact with their family members who live far away from them. For many women, the free mobile phone from the programme arrived at 'the right time'. --- Enhancement of well-being Repeatedly, newly arrived refugees and migrants endured many burdens, particularly emotional burdens, and yet they had few that they could rely on. However, our programme helped to increase the well-being among the women in the study. It not only offered a sense of happiness but also lessened social isolation among the participants. --- Increasing sense of happiness Participating in the peer support group programme and having access to a mobile phone augmented a sense of happiness among the women. Some women even suggested that the day they commenced the programme was 'a beautiful day' for them. The women also talked about feeling happy to be able to meet others in the peer support training sessions. This sense of happiness took away the worries that most women had in their life, to the extent that some women declared that they have become a 'free' person. Access to a mobile phone allowed the women to be connected with their family members at times when they had to be outside their home for an appointment or a class. This helped to lessen their anxiety about those who are left at home, particularly their young children. Importantly, it became apparent that the phones facilitated mutual emotional support among the women. When I call my friends, I share all my feelings with them and I take all of my stories, my concerns and my worries out of my chest. So it makes me feel much better. The women talked about the complexity of their lives as refugees and remarked on the value of the phone as a tool to harness the peer resources in response to their emotional needs. --- Reduction of social isolation As the programme allowed the women to connect to others, this diminished their sense of isolation. Refugee women who were mothers in particular tend to feel more isolated in their new homeland. For the women in our study, although they had children in their lives, things were not the same as they were back in their homeland. Children tended to have a separate life due to school or work and seldom had time for their mothers. This led to feelings of isolation among these women. However, having access to a mobile phone allowed the women to call others and talk instead of not having any meaningful activity to do. This also led to feelings of happiness among the women. Now having this number . . . having this mobile . . . I call my friends you know . . . I call my children even in America [and] I′m here. If it wasn′t this telephone I would be just watching television, you know. I don′t even understand what they are saying, just the picture. But now this telephone has kept us laugh. We call each other and we talk and you laugh . . . We make joke on the phone and we laugh, and you know the more you laugh the happier you are. It has brought us back some memories . . . some of the things that we used to do back home. --- Increasing social support Due to the increased social interaction between individuals through the programme, social support between group members was created. Repeatedly, the women spoke about the emotional support that they received from others in the group. The women also received tangible support from group members through knowing each other and through the use of mobile phones. Importantly, the mobile phone and access to peer group members on their phone on speed dial took on life-saving significance for some women. Once I was at TAFE and doing English classes, I suddenly didn′t feel well. I got stomach-ache and the teacher had to call ambulance. I couldn′t call my husband, but because of this phone, I called one of my friends. I asked her to let my husband know that I was not feeling well and I was taken to the hospital. So at that time, I found out how important this telephone was. Otherwise he wouldn′t know. Peer support embodies both receiving and giving support to others. Around practical support, the women became aware of not only their own but other women's needs and availed themselves to support others in their network. --- Provision of empowering experiences Our programme provided several empowering experiences to the women in the study. Many women had not had any opportunity to own technology, such as a mobile phone or computer, in their own country. Having access to new technology such as a mobile phone was an empowering experience for these women. The women felt proud of themselves for having knowledge about, and skills to use, a mobile phone. Additionally, what the women learnt from the peer support training programme empowered them to acquire further skills or learn more about other issues which would become valuable for their lives in a new living environment. The programme assisted the women with the acquisition of English language and provided more opportunities to practice English. The women believed that the connection that they had created through the peer training sessions and the free-call mobile phone gave them an opportunity to be an 'informed' individual who would have better knowledge about things around them. They became more confident about travelling to places outside their home or community, which led to feelings of empowerment and self-capability among the women. We got this phone and we contact each other, and then we go everywhere. We know so many places. So that has improved it [life]. We know so many places and we can go everywhere now. Access to mobile phones also made things easier for the women. Mobile phones enabled the women to settle into Australia with better ease. For example, it increased their ease of obtaining essential ingredients for cooking. The mobile phone also allowed the participants to connect with healthcare providers more efficiently. For women who were mothers, the mobile phone allowed them to deal with emergencies that might arise regarding the health and well-being of their children who were at schools. I have been in trouble many times, you know, with my children. Sometimes there is an accident, and they call me to let me know that it happened and that I needed to come or they were going to send the child to the hospital. One of the children got sick in school, so they called me and I couldn′t call them back because I didn′t have the credit. So I went to school and when I went to pick up the kids, all these incidents already passed. They told me what happened, and I felt that . . . where was I when I was needed? But now with this one [mobile phone], everything is there immediately. If anything happens, 'come now', I will be able to because I have the means to call them back. --- DISCUSSION In this article, we have focused our attention on the unique aspects of our programme that helped to enhance the health and well-being and ease the settlement process of many recently resettled refugee women. It has been suggested that participating in peer support groups provides beneficial effects to group members . The findings of our project support this notion. However, our project also reveals that it was the combination of participation in a peer support group programme and access to a free-call mobile phone that provided the best effect on the well-being of our participants, who were isolated and faced multiple complexities in life refugees . Roth and Crane-Ross and Schutt and Rogers have suggested that there may be some special features that enforce the positive effects of peer support group. We content that the special feature of free mobile phone access contributes to this positivity. The mobile phone is not only a 'unifying medium for information exchange' , but also 'a social amenity' and a means for increased economic opportunities for individuals . In a study of mobile phone use by immigrants from Guinea-Bissau in Lisbon, Portugal, Johnson observed that mobile phones are widely used to facilitate relationships within the heritage culture in Lisbon. Importantly, it has been evidenced that the mobile phone can function as a health promotion tool . This has been witnessed in our study. For example, reconnection is an important part of recovering from trauma and difficulties . For the women in our study, having access to a free-call mobile phone allowed them to 'reconnect' with others and family members as well as their traditional ways of life . This helped the women to feel less worried and isolated. Although some women had their own mobile phone prior to participating in our study, our data showed that the freecall element of our mobile phone was important for them. Due to their low income, they frequently ran out of credit in their own mobile phone. Mobile phone calls are expensive, and as most of them are on a prepaid plan, they simply could not afford to make the kind of calls they had made in our programme. They referred to the phone we provided as the 'magic phone' because it had unlimited credit. Although some participants said that they were disturbed by unwanted calls at inconvenient times, the benefits of having access to a free mobile phone outweighed this drawback. In our study, peer support is viewed as a subset of social support in which relationships are formed between individuals who are similar to each other. The initial training was undertaken in peer groups, but the provision and receipt of social support extended into the broader community. In our study, peer support training enabled the participants to establish communicative relationships among participants from the same communities, whilst the mobile phones augmented the peer group relationships, and relationships with a small number of people and institutions external to the peer group. Our study builds on the role of peer support in refugee resettlement by adding a reliable communication channel that enables social network development, which in turn influences the acculturation journey of refugee women . In the following sections, we discuss several salient issues emerging from our study. Ngum Chi Watts, 2012;Benza and Liamputtong, 2014). Most migrant and refugee women have to deal with multiple stresses associated with relocation and social adjustment when settling into a new homeland . For refugees who have to deal with multiple difficulties, isolation can be a 'compounding factor' which make their life situations worse . As a result of participation in peer support trainings, as Wallerstein suggests, 'social isolation may be diminished', and this led to the improvement of health and well-being among the women in our study . In an online support group research conducted by van Uden-Kraan et al. , the participants strongly experienced what the authors termed as 'enhanced social well-being'. Participation in a support group resulted in increased social contacts as well as decreased loneliness. Our results similarly showed this 'enhanced social well-being', as participation in peer support groups helped to reduce isolation and loneliness among the women. Additionally, the social support helped the women to feel that they were not dealing with life's challenges alone . We contend that the support that the women received from their peer support group is crucial to their health and well-being and allowed them to deal with their vulnerabilities in a new homeland . Additionally, peer support enhances empowerment among individuals in the group . Through learning and sharing during the peer support training and communicating on their mobile phones, the women in our study cultivated a sense of their own abilities and had an opportunity to reinforce connections with others. This helped to transform their lived experiences from 'being socially isolated individuals' to being part of a larger community . This, we believe, is the 'personal empowerment' process for the women in our study. Although peer support emphasises 'individual strengths', it simultaneously moves 'towards autonomy' as well as 'community building' . Thus, peer support can be empowering for both individuals and their communities. Wallerstein suggests that participation in a community, and a sense of community belonging, has consistently been seen as a predictor of health and well-being. Wang and Hu similarly contend that a sense of community and social support received from others in the community can have a protective health effect on individuals. This is apparent in our study. Having a sense of community connection not only reduced the participants' sense of isolation but also helped them to settle in their new homeland with greater ease. Research has shown that, for most refugees and immigrants, a sense of belonging to one's ethnic community is crucial for the health and well-being among these vulnerable people . Empowerment, Wallerstein suggests, is a 'social protective factor' which can also be seen as a 'health enhancing strategy'. This is clearly seen from our findings. Many women suggested that the connections and knowledge they had cultivated from the programme made them feel 'brave' and 'safe' enough to get out of their community and to do things that they previously had no opportunity or courage to do. This has created the feeling of empowerment and self-capability among the women. The connections that were cultivated through the programme allowed the women to perform tasks which are more health promoting, for example having a 'chat', and obtaining advice from others. In conclusion, our programme provided evidence that appropriate peer support strategies can be incorporated into programmes designed to assist refugees with health and well-being enhancement, as well as acculturation and resettlement needs. We argue that mobile phone technology is ubiquitous and the issues are about making access possible for specific population groups and identifying the uses that are most important to members of particular population groups . Our programme has shown that, by tapping on community resources to ameliorate personal or resettlement issues, the burden on service providers could be reduced. The findings of this study also offer a model for future research and health promotion programmes regarding people from other refugee backgrounds, within Australia or elsewhere. --- Peer support and health enhancement We have shown in this paper that participation in peer support group is a health-promoting behaviour. As Kafaar et al. theorize, by participating in peer support group, individuals will receive some kinds of benefits, such as assistance for dealing with difficulties in life and combating against isolation. Peer support, according to Mead et al. , is a system of gaining and bestowing assistance. It is operated within the 'principles of respect' and 'shared responsibility' among group members. Peer support is also about having empathetic appreciation of the situations of others through shared experiences. When individuals in the group sense that they have shared experiences with others, a connection is created. Peer support bestows 'a sense of connection, belonging, and community' which frequently falls short among marginalised individuals , and this clearly is the situation of refugees, particularly those who are newly arrived, including the women in our study. Clearly, these are health-promoting behaviours resulting from having access to peer support groups. Peer support is a form of social support, which functions both at the individual as well as community levels . As social support theory suggests, support is reciprocal , the women in our study gave help to others as well as received it when needed. This was particularly so among older women who provided support to young women with no parents living in Melbourne. This support was essential for young people who have experienced loss and grief and for successful settling into a new life . Social support provided by the older women enhanced a sense of belonging and security among the younger women. Several authors have theorised that giving and receiving social support can be health-promoting behaviours . The support that one receives from social ties can act as a buffer against health difficulties . Barnes and Aguilar argue that being part of a community offers 'an important sense of belongingness and social identity'. It also promotes an opportunity for the creation of social bonding, resulting in increased social support and improvement of emotional well-being among individuals. This was evident from our findings. Additionally, the women in our study emphasized the practical support they received and provided to other peers in their social group . Peer support was developed into a complex system that benefitted not only the women, but also the community. The women became aware of not only their own but other women's needs and availed themselves to support their friends. --- Peer support and social well-being Refugees and immigrants tend to face social isolation in their new homeland , and this is particularly marked for recently arrived individuals . In our study, social isolation, which was experienced by all, was particularly pertinent for women who are mothers (Liamputtong, 2006;

In this article, we discuss qualitative findings basing on the experiences of refugee women living in Melbourne, Australia, who participated in a peer support training programme and received a free mobile phone. We pay attention to social support as a health enhancing strategy and empowerment that occurred among the participants. Participation in peer support groups and access to a mobile phone were beneficial for the women. Peer support functioned as social support among group members. The programme allowed the women to be connected to their families and the wider communities and assisted them to access health care and other settlement aspects with greater ease. It also increased personal empowerment among the women. Our programme shows that by tapping on community resources to ameliorate personal or resettlement issues, the burden on service providers can be reduced. Our findings also offer a model for future research and programmes regarding refugee people elsewhere.

Introduction I ntimate Partner Violence is a public health problem with diverse mental, sexual and socioeconomic repercussions for the victims [1]. Like other non-communicable diseases, IPV contributes greatly to preventable morbidity and mortality statistics worldwide [2]. Globally, one in every three ever-partnered women of reproductive age has experienced at least one form of IPV in their lifetime [1], showing the pervasiveness of the problem. Research evidence has shown that the prevalence of IPV is higher among young women than older women in both high and low/middle income countries [3,4] Prevalence of IPV among adolescents and young women in Africa and sub-Saharan Africa has been estimated to be as high as 67.7% [5,6]. The experience of IPV at a young age either as a victim or as a witness puts girls and young women at risk of experiencing more IPV in adulthood [7]. The prevalence of IPV among adolescent and young women in Ibadan is as high as 45% [8]. According to the socio-ecological model proposed by Heise [9], IPV is a multidimensional phenomenon. The dimension to the study of IPV is an interplay of the individual, relationship, and sociocultural factors. A singular factor is not enough to predict victimization or perpetration of IPV. The first level is inherent personal factors that increase the likelihood of being a victim or perpetrator of violence. These factors include sex, age, level of education, income, substance use, witness of abuse, etc. The second level examines close relationships e partners, friends and family member factors that may increase the likelihood of experiencing or perpetrating violence. An individual's relationships influence their behaviour and contribute to their experience in life. These relationship factors include male dominance in the family, alcohol/substance abuse, adherence to traditional gender roles, and level of education among others [9]. This study is based on the second layer of the socio-ecological model. This layer examines close relationships such as those with partners, family members, peers e that may influence the experience of IPV. The level of parental education often determines their socioeconomic status and attitude to life. It may also influence their belief and adherence to social norms, which could affect their children's lives. The quality of an individual's relationship with the family members, especially the mother, protects against IPV victimization and perpetration [10]. Parents' beliefs and social orientation may dictate the child's views about life, level of exposure, as well as the kind of decision the child makes. The parents' primary relationship with the daughter, especially the mother-daughter bond is often characterized by a culture of silence that trivializes violent acts and makes women feel guilty after being abused. This secret feeling of shame linked with female sexuality that is unconsciously passed down to the daughter in the parentechild relationship impacts on a child's orientation and experience in life. At the relationship level, several studies have focused on a partner's and not the parent's characteristics that may influence victimization of young women by their partners. Therefore, this study assessed the influence of parental characteristics e level of education, occupation, family structure, parental conflict on young women's experience of IPV in Ibadan, Oyo State. --- Method --- Study area The study was conducted in the five Local Government Areas of Ibadan metropolis. Ibadan is the capital of Oyo state, Nigeria, and the third largest metropolitan city in the country. The major residents in the city are the Yoruba ethnic group who are engaged in different artisanal, trading activities, and civil service. Even though an urban city, there are several traditional settlements within the city centre. Ibadan metropolis has a total population of 1,343,147 based on the projected 2020 population estimate. Fifty-one percent Ibadan's population are female, and 20% are adolescents and young women [11]. --- Study design and sampling This was a cross-sectional community-based household survey. The sample size was calculated using sample size formula for single proportions. Assuming IPV prevalence of 42.3% among young women in low-income communities in Ibadan [8], type-1 error of 5%, cluster effect of 2.0, and 10% non-response rate, we obtained a minimum sample size of 825. A total of 1050 young women were interviewed. The study participants were young women aged between 18 and 24 years, who were currently in a relationship with a male partner. Respondents were selected using a multistage sampling method. From the list of 12 wards in each of the five LGAs, two wards each were selected by simple random sampling. Thereafter, two communities each were selected from each ward by simple random sampling. Households in selected communities were visited and one young woman was selected per household. A young woman was eligible to be selected if she had or currently was in a relationship for more than three months, resided in the selected community for at least six months, and gave consent to participate in the study. --- Data collection and management Data were collected with the use of a 28-item semi-structured interviewer-administered questionnaire adapted from the WHO Multi-Country Study on Women's Health and Life Events questionnaire. The questionnaire had three sections; . Interviewers had completed their university degrees, were trained on how to collect unbiased data and how to maintain ethical conduct when researching on GBV using the WHO guideline of ethical conduct of violence research [12]. Data were collected between October and December 2020. Interviews were conducted in a private space in the respondent's home. Data was captured through the use of Computer Assisted Personal Interview . Study variables: the outcome variable was the past-year prevalence of physical , sexual and psychological IPV. The study assessed past-year prevalence of IPV rather than lifetime prevalence to reduce recall bias. Some of the young women were also in their first intimate relationship for less than one year. These outcome variables were defined as Physical IPV -if respondent reported experience of any of the following from her partner in the last 12 months: being slapped, pushed, pulled hair, hit, punched or kicked, choked on purpose, or threatened to use, or actually used a knife or other weapon. Sexual IPV -if respondent partner has ever physically forced her to have sexual intercourse, or she has had sexual intercourse because of fear. Psychological IPV -if respondent has ever been belittled or humiliated, insulted, intimidated, threatened, or personal belongings destroyed by partner. Explanatory variables were parent's characteristics: type of marriage union , father's level of education , mother's level of education , parent's marital status , father's occupation , mother's occupation , mother's experience of IPV . Data were analysed using Statistical Package for Social Sciences version 20.0. Respondents, partners and parents' characteristics were summarised using frequency and percentages. A Chisquare test was used to test the association between the dependent and independent variables. Binary logistic regression was used to determine the predictors of experience of IPV among young women. The level of significance was set at 5%. --- Ethical issue Ethical approval for the study was obtained from the University of Ibadan/University College Hospital joint ethics review committee . The study adhered to the WHO ethical consideration recommended for IPV research. Participation in the study was voluntary. Informed consent was obtained from each participant after ensuring that respondents understood the purpose of the research. The study ensured no names were collected and women who became traumatised or requested such support were referred to nongovernmental organisations for services that include psychological support, legal and medical care. --- Results A total of 1050 young women were interviewed. The mean age of respondents was 21.0 , and the majority were in the 20e24 years age group. A total of 772 of the young women were educated to secondary level, while 15.6% had at least one child. Socio-demographic characteristics of the respondents and parents are presented in Table 1. Six hundred and thirteen women were in a monogamous union. 645 of the fathers had completed secondary education and above, while 656 of the mothers had completed secondary education and above. 624 of the parents were reportedly married. 349 of the fathers and 220 were artisan and employed respectively. The majority of the mothers were traders. 315 mothers experienced IPV. Fig. 1 experienced sexual IPV and physical IPV respectively . --- Parents' characteristics by IPV experience The result of the association between parents' characteristics and each type of IPV e physical, sexual and psychological are presented in Table 3. Bivariate analysis revealed that the experience of physical IPV among respondents were polygamous family background, father's level of education, mother's level of education, parent's marital status, and father's occupation . Factors that were associated with experience of sexual IPV among respondents were father's level of education, mother's level of education, parent's marital status, father's occupation, and mother's occupation . Factors that were significantly associated with experience of psychological IPV were polygamous family background, parent's marital status, mother's occupation, and mother's experience of abuse . --- Predictors of IPV experience among respondents For physical violence, young women whose parents were widowed were significantly more likely to experience physical IPV than those whose parents were married . For sexual violence, a respondent whose father had at least completed his secondary education was less likely to experience physical IPV than those whose father had less than secondary education a Significant values at p < 0.05. . While the father's employment significantly increases experience of sexual IPV , mother's employment significantly reduced the experience of sexual IPV . For psychological IPV, young women whose parents were separated/divorced were more likely to experience psychological IPV than other young women . Similarly, young women whose mothers were abused were more likely to experience psychological IPV . --- Discussion Intimate partner violence is a global and pervasive violation of human rights that affect women and girls of all ages. Intimate partner violence is prevalent in Nigeria, where patriarchy is a socio-cultural system that privileges males and enthrones masculine domination of women. African culture nurtures this pervasive and resilient system where the man/ husband is the head of the household/family and he controls productive resources, labour force, and reproductive capacities based on the notions of superiority and inferiority. This socio-cultural norm denies women equal rights with men, leaving women underserved, underprivileged and alienating them from educational and economic opportunities which predisposes women to the risk of IPV [13,14]. This study assessed IPV experience and the influence of parental characteristics on occurrence of IPV among young women in urban communities. Our study findings showed the pattern of IPV experience among the participants, the characteristics and socio-economic composition of the parents. Our study showed that psychological IPV was the most prevalent form of IPV experienced by young women. Other studies have also reported higher prevalence of psychological IPV than other forms of IPV [15,16]. It is noteworthy that the prevalence of psychological IPV is higher than the one reported in other studies. Psychological IPV is the most pervasive form of violence and more tolerated by women because it is the underpinning of all forms of abuse, leaves no physical evidence, and unfortunately, the consequences are similar to those of other forms of IPV. It is a phenomenon that is shaped and influenced by acceptable societal norms and factors of social culture [13,17]. Higher levels of the father and mother's education reduced experience of physical and psychological IPV but not significantly. Parent's level of education has been reported to pose a risk to IPV victimization. Parent's education less than high school level increases risk of IPV. Father's level of education provides an estimation of the household income and socio-economic status of the family [18]. Similarly, this can predict the educational attainment of the girl child because the father may selectively send the boy child to school in a situation where the family are of poor socioeconomic status and then marry off the girl child, sometimes for monetary gain. Girls and women with low levels of education have reduced chance of economic empowerment which has been linked with increased IPV experience which in turn culminates in a cycle of poverty and then IPV [16,19]. In addition, parents with low levels of education may support rigid traditional gender roles and hence, support their daughters' victimization by their partners. It is also possible that the father is a perpetrator and the mother has been a victim all her life, thus, they normalize violence and expose the children in such family to abuse, a documented risk factor for IPV victimization [20]. The father's employment increased the experience of physical and sexual IPV among young women, while the mother's employment reduced experience of sexual and psychological IPV. A father that is employed whether in the formal or informal sector may spend less time with the family leaving no room for family discussion or update as the case may be. It may also be that the daughter cannot approach such a father to report an erring partner. On the other hand, a mother that is employed in the formal sector is more likely to be better educated, exposed to information, and may exercise some form of economic control in the home. The mother may also be able to provide some measures to prevent victimization of the daughter such as good education and a social network. This already shows the imbalance in contribution to the family income which is an established risk factor for IPV [19]. This may predispose young women to experience IPV in their own relationship, but also, because IPV victimization is sometimes intergenerational [21]. A mother's experience of abuse significantly increased the experience of psychological IPV by young women. This has been confirmed by other studies that witness parental violence as an established risk factor for IPV [22,23]. The pathway shows that children who witness parental violence have most likely been abused by either or both parents. Secondly, the children may have grown up to accept abuse as a way to resolve conflict, and thus normalize it in their own relationships. In addition, such children lack emotional communication and support in the family relationship as a result of the life crises. Hence, they grew up unable to adjust, or control their emotions and are constantly in need and searching for care and love [24]. --- Conclusion Although the study was conducted in an urban area, the different socioeconomic strata in the urban area may have contributed to the level of IPV experience reported. For example, living in low-income communities constitutes risk for experience of IPV. There is a low level of education, low socioeconomic status, high level of adherence to traditional norms, and community acceptance of wife beating [25]. These aforementioned factors coupled with parental ignorance about IPV place young women at risk of violence. Despite the fact that the parental characteristics considered in this study are limited to the type of family structure, marital status, level of education, and occupation, it can still be deduced that parental characteristics influence a young woman's experience of violence in her relationship. This study has provided baseline information for a large-scale study to examine other parental factors such as age, level of income, religion, alcohol or substance use etc. that may influence experience of IPV among young women. --- Recommendation Ending IPV among young women requires intervention programmes that will inform and promote culture and values of family well-being, emphasizing respect for women and men's roles in the home. In addition, governments and stakeholders should develop and implement a policy on cultural awareness for social change. ---

Background: Intimate Partner Violence (IPV) is a global public health problem. This study examined the influence of parental background on the experience of IPV by young women in Ibadan, Nigeria. Method: A cross-sectional survey was conducted in the five Local Government Areas of Ibadan metropolis. One thousand and fifty young women aged between 18 and 24 years were selected using a multistage sampling method to participate in the study. Data was collected using a 28-item semi-structured questionnaire. The independent variables were the parents' education, marital status, occupation, and mother's experience of victimization. The dependent variable was previous experience of physical, sexual, and psychological IPV. A Chi-square test and binary logistic regression were used to test for association. The level of significance was set at 5%. Results: The majority of young women had experienced psychological IPV (55.0%). Two-thirds of fathers (61.4%) and mothers (62.5%) had completed at least secondary education. More than half (59.4%) of the parents were married. Parents' marital status was significantly associated with experience of sexual and psychological IPV. While the father's employment significantly increased experience of sexual IPV, the mother's employment reduced experience of sexual IPV. Abuse of respondent's mothers increased experience of psychological IPV. Conclusion: This study has provided information that parental characteristics such as father's employment and mother's experience of abuse have a significant influence on a young woman's experience of IPV. Thus, intervention programs among young women should include parents.

In the age of the search engine, the claim has been made that we are 'outsourcing memory and knowledge to the internet' and that this 'is making us meta-ignorant' because we are now 'unaware of what we don't know'. 1 Understanding how people access and use information is more important than ever if information providers are to achieve effective knowledge transfer to consumers. This study contributes to the currently small but growing body of scholarly research on the legal information experience. Scholarship in this emerging field focuses on the lived experiences of people who access legal information: how sources of information are located, engagement patterns with those information sources, and how legal information is understood and applied to individual situations. Information experience may be understood as a 'complex, multi-dimensional engagement with information in realworld contexts'; 2 information experience 'integrates all information related-actions, thoughts, feelings and has social and cultural dimensions '. 3 Legal information is now readily accessible to members of the public via the internet. 4 A Google search for a legal topic will reveal a plethora of government and non-government legal sources, with links to statutes, cases, secondary legal materials, DIY kits, self-help groups and FAQs. Lawyers are taught legal information retrieval and analysis skills at law school. They know how to find authoritative and current legal resources that are relevant to solving a specific legal dilemma, and how to find reliable sources directly without mediation through a search engine. Non-lawyers seeking legal information will not necessarily have these skills or access to the appropriate resources. For citizens in a liberal western democracy with the rule of law at its core, 5 it is critical that the legal information experience is effective. However, there is still relatively little known about how non-lawyers access and use legal information. 6 This means that legal information providers have an inadequate evidence-base to inform the effective design and delivery of legal information to nonlawyers. The project reported in this paper had a simple objective: to understand the range of legal information experiences. The existing body of work in the legal information experience has centred on the information needs of law students 7 and lawyers. 8 Two key Australian studies are Scott's work on how people access legal information via the internet, 9 and Edwards and Fontana's review of the legal information needs of older people. 10 Our research extends this work by exploring the lived experiences of non-lawyer consumers of family law information in post-separation contexts. 11 In 2016, the Australian Bureau of Statistics reported '118,401 marriages registered and 46,604 divorces granted'.12 This figure does not include the separation statistics of de facto relationships. Family law information is clearly an important legal need for significant numbers of Australians every year. The article begins with a brief explanation of the project's design and methodology. We then consider the key issues arising in the project interview data about the role of internet searches in the family law information experience. Three central themes emerge from the data -information complexity, source preferences, and difficulties in applying information to one's own individual situations, meaning that the information accessed by 'Googling' does not necessarily help to inform legal choices. --- Project design and methodology This qualitative empirical research project was funded by an Australasian Institute of Judicial Administration research grant. The project team comprised interdisciplinary researchers from law and information science. The aim of the project was to explore the information experiences of people who had phoned the Federal government-funded Family Relationships Advice Line -a national telephone service operated by Relationships Australia to provide relationship and separation advice, information and referral, but not legal advice. 13 Information experience analysis is now a distinct emerging domain of information science research, adopting a 'holistic approach to understanding peoples' engagement with information', taking 'into account the interrelations between people and their broader environments in a manner which considers people and their world as inseparable.' 14 This qualitative, interpretive approach is established as methodologically robust, bringing a unique analytical perspective to the concept of legal information, and to an analysis of the legal information experience. In-depth interviews were used to appreciate participants' perspectives and reveal the meaning of experiences from their viewpoint,15 and gain more complex personal narratives. A sample of twenty16 interviews was used. While this sample size may appear small compared with quantitative research methods, it is a valid standard-to-large sample size for research of this nature, and is 'of sufficient size to gather suitably rich descriptions of people's varying conceptions about the phenomenon of interest'.17 Phenomenographical research methods do not seek to categorically prove theory, they seek to explore and enhance understandings of specific phenomena -for this reason the sample size reflects where a point of saturation in emerging themes is reached. 18 The data was analysed using thematic analysis -an analytical method that identifies patterns or themes within a data set, 19 providing insights in relation to the subject's 'relationship within the phenomenon being researched'.20 --- The role of Google in the post-separation legal information experience In this section, we present some of the project findings that are salient to the participants' experiences of finding and accessing legal information in relation to post-separation parenting arrangements, with a particular focus on participant experiences relating to the use of Google and other search engines. The data revealed three inter-related issues, namely: the complexity of online information sources; the participants' preferences for informal and personalised sources; and the difficulty of applying online information sources to the participants' individual situations. --- Managing the complexity of information content and sources Participants struggled to negotiate the complex legal information environment, including identifying and reconciling different sources of information. Although the digital era offers significant opportunities for people to access legal knowledge and information online, the ubiquity of online resources means that those who 'turn to Google' will find they need to process and manage large amounts of information. For example, using a search term such as 'my rights as a father' will return almost 30,000,000 results, predominately from the United States and the United Kingdom, with very little Australian or government-funded content. Without the skills to filter this information it can be confusing, overwhelming and complex. The dominance of Google as a search engine also means that the company's specific algorithms impact how information is presented -an important issue but one outside the main focus of this article. 21 Several participants reflected on the challenge of obtaining a clear picture of their legal position when faced with conflicting or confusing sources. A number of participants used language depicting their search for information as a journey or quest, presenting obstacles that required significant effort to overcome. Almost all participants began with online sources, with a Google search a frequently-mentioned starting point. However, the resulting information often proved inconsistent or confusing, leading to a desire for clearer or more personalised outcomes. Fran, 22 for example, recounted: 'I went on the Family Law Court website … it came up with a phone number so that's why I called them … I really couldn't find what I was searching for. To be perfectly honest, I find those websites extremely difficult to navigate … I find them really hard to work out'. Ingrid's initial encounter with online information left her feeling tired and overwhelmed: 'I think I did Google early on what was necessary … I found a lot of it wasn't really clear'. Darius commented that he used a Google search but 'actually I have done so much homework, I couldn't decide which one is not useful and which one is useful -because so many information [sic], I'm currently kind of overwhelmed, you know? I have so many issues that I have to deal with, and I still couldn't figure out which information is helpful and which information is not.' There was an overwhelming sense from participants that they were unable to enact clear strategies to make sense of the legal information they found through online searching. Participants immersed themselves in the information experience, looking for anything that might appear relevant, or lead to the next step to locate further information. As one participant, Tom, observed, 'when you're looking for stuff … you're just jumping down rabbit holes looking for stuff, and popping out the other side going, "No, that's not what I was looking for".' Some participants had a positive experience of accessing online materials in combination with other formal and informal sources to meet their overall information needs. Brian observed, for example, 'Google has been the best friend and I've Googled absolutely everything there is to do with separating families.' Anna noted her information source was 'mainly through the internet, so I've just been on Google and that's how I found out about the Family Service Centre'. Noel commented that he 'found more than enough on the internet … I virtually had everything I really needed. In between the Family Care Centre, my solicitor, and the internet, I found all my answers really … There's more than enough information out there'. Several participants relied on face-to-face or telephone information to supplement or bring clarity to online sources. For example, Noel reported that, in addition to using the internet, he 'went to [his] solicitor when this happened and we just had a good old chat'. According to Ethan, friends and acquaintances were an important source of information, enabling him to bypass the complexity of online material: 'Pretty much word of mouth from other people, asking people and all that sort of stuff, those that have been through this stuff before … I just asked them … they've done the research and I've just listened to them because they've obviously researched it and they've just passed it on to me'. However, these more personal interactions also gave rise to further confusion for some participants. For example, Bobby expressed frustration that 'I've been asking people and it's just been confusing and people are saying different things'. Interestingly, participants indicated that formal legal advice was rarely experienced as the most important source of information. Despite its reliability and authoritative nature, it was simply one of a number of information sources evaluated by the participants as part of their legal information experience. This indicates that online searching is not only a frequent starting point for accessing legal information, but the resulting array of diverse sources represents a more general framework for the legal information experience. The information sources gained through online searches are considered alongside more traditional forms of legal information and advice, resulting in a complex information matrix that parties must interpret for their own purposes. Google is therefore both a friend and a foe in the post-separation legal information experience. It ensures that information is readily obtainable, but the resulting data is not necessarily accessible in the sense of being manageable and understandable. This led participants to express clear and consistent preferences for more informal, personalised and easy to apply sources of information, as discussed in the following section. --- Preferences for informal and personalised sources The study participants expressed clear preferences for particular sources, informed more by issues of accessibility, familiarity or the trusted nature of the information than by the expertise or authority of the source. A recurring theme was a preference for personalised information over general sources, and for face-to-face or telephone communication to supplement online information. Participants generally found personalised sources of advice provided a level of clarity or reassurance in response to the confusing and overwhelming nature of online sources. Bobby expressed this desire directly: 'I haven't really understood a great deal of everything. And I guess that I sort of have to sit down with someone, faceto-face and sort of understand my rights … you know, what I'm entitled to with money. So if someone just sat with me face-to-face, I think I could understand a lot more. But as I said before, I'm not really understanding a lot from the internet'. Bobby then described the reassurance she felt when she received a telephone call from a Family Relationships Centre: 'I'm sort of really not understanding a lot of what I'm reading … But the lady that I spoke to yesterday from the Family Centre, she was quite thorough with what she was telling me, so I could sort of understand a little bit more as to what I was reading on the internet … I was quite terribly relieved that I had someone that was going to call me back in a week or two and sort of guide me and advise me as to what my rights are'. Ethan also reported a strong desire for personal interaction, both to obtain more concrete information and for human contact: 'I just found a phone number and called … I just knew I needed to call someone and I just wanted to find a phone number to be honest. I didn't really care about the information'. The search for relatable and concrete information led some participants to rely significantly on the advice of friends, family and community leaders. Darius explained that 'I used Google search … I talked to my friends … he advised me to make some calls … and advised me to seek information online and from government website… It's always nice to have somebody who you actually feel close to, to talk about all these issues.' Kerry similarly recounted relying on friends and family, commenting that 'they've been through it and there's no doubt, you take a great deal of information through them. … [M]y brother has been through it as well many, many years ago and you know, you take notice of what they have to say.' Online searching is therefore an important element of the legal information experience, but it does not fully satisfy the legal information needs of post-separation parties. Rather, a personalised supplement is preferred so that there is a human connection that can support making the information relatable and understandable. Participants commonly reported an iterative process of information searching and analysis, where online searching is supplemented by informal advice and discussions, which in turn leads them back to the internet, perhaps in a more focused way. These experiences show that although Google and other search engines are an important source of legal information for parties postseparation, they are not viewed as a substitute for more informal or personalised information. Indeed, in some ways, the nature of the online information environment reinforces the need for traditional information sources. --- Difficulties with the application of information The third key issue relates to the observation that participants consistently struggled to apply legal information to their individual circumstances. Here, a distinction is necessary between legal information and legal advice, but it is a difficult and unclear distinction especially in the online environment. Several participants commented on the depth and breadth of information available on the internet, but struggled to apply it to their own context and situation. This concern can be seen from the comments of Bobby and Ethan above. Brian similarly commented that the large volume of information was challenging to apply: Look all of it, in terms of it … every, every little bit would be helpful in some way, but the scope of the information available at the moment is not just an easy walk-up start, to say 'if you are a separating family, here are the things that you need to consider and here are the procedures that you need to follow, and here are the things that might be important if you have children'. It wasn't … like, there's no prescribed format or something like that to follow. Some participants sought formal legal advice in an attempt to understand how the law applies to their situation. In other cases, participants reported discounting or overriding legal advice based on what they viewed as more directly applicable or concrete advice from other sources. Steve reported becoming frustrated with formal legal advice and turning to informal advice from family members, which he viewed as more applicable to his circumstances: 'I, again, wasted a lot of time with this Legal Aid solicitor until I spoke to my cousin, who um had been in a similar situation and she, she basically advised me to not waste time, that it's … that it is quite easy and acceptable to represent yourself'. Several participants reported relying on information from friends or family that included substantive advice. For example, Vinnie reported initially consulting websites 'like the Centrelink website and the Child Support', but found they contained similar generic information, leading him to rely on more tailored informal advice from his social circle: 'I mean they're all linked pretty closely together so they had some pretty good articles on there. … [B]ut I had advice from a friend of mine who is a mortgage broker to just go through and document that we want to share 50/50 custody of our son.' The experience of these participants reinforces the conclusion that, while Google represents a critical component of the accessibility of information in the legal information experience, it is not of itself sufficient to satisfy the information needs of parties in post-separation contexts. These post-separation needs include legal advice, not just legal information. Parties prefer more informal and trusted sources, and online information often proves difficult to apply to their individual circumstances. Personalised information was viewed by parties as helping them understand their own individual situation, but needs to be timely and affordable. Formal legal advice does not necessarily meet the parties' needs, leading them to rely heavily on friends and family as a supplement to the generic and complex information on the internet -which may or may not meet unmet legal needs. --- Conclusion Living in an age of the internet brings with it particular informational challenges. As Wurman has observed, 'We are like a thirsty person who has been condemned to use a thimble to drink from a fire hydrant. The sheer volume of available information and the manner in which it is often delivered render much of it useless to us'. 23 While the availability of online legal information presents great opportunities for the rule of law to be maintained by providing citizens with legal information, this research project has shown that it undoubtedly also presents significant challenges and is no panacea. A number of clear messages arise from this study for legal information providers such as government agencies, courts and mediation service providers. Information providers need to be conscious of the benefits that internet searches provide consumers of legal information, accessibility being the key factor. However, there is also a need to understand and check the complexity and diversity of the web of information that consumers are accessing and managing, including not only online sources and forums, but also friends and family, and popular media. Consumers of legal or dispute resolution services are likely to be well-informed in the sense of having access to a large amount of information from different sources, but may nonetheless be poorly apprised about how this applies to their situation, or the best strategy for them to adopt to achieve a desired outcome. They may also need assistance in reconciling incorrect or inapplicable pieces of information that may be dated or from another jurisdiction. Legal information provision policy therefore needs to be informed by two principles in light of this picture. The first is that providing legal information on the internet is important, but it is not of itself sufficient. The second is that personalised supplements to online information are critically important both for engaging consumers of legal information and for the rule of law. Such personalised supplements should optimally be available through human sources who are relatable and can explain complex concepts in a way that supports understanding and takes account of the parties' circumstances. Artificial legal intelligence may be a way of meeting some of these needs of consumers, while containing costs. 24 However, the results of this study also sound a note of caution about the prospects of human providers of legal advice being replaced or supplanted by a wholesale reliance on technology; there is a particular need for providers to be wary of how their information presents in specific search engines. Online information is a powerful tool that can empower users of the legal system. However, consumers nonetheless report consistent preferences for human contact in their information experience. This is partly to obtain tailored information, but also to meet the desire for a more grounded and focused informational experience compared to the relatively generic and impersonal setting of the internet . Providers of legal information can harness online information as a way of connecting consumers with services that meet this need. The challenge is to provide sources of information that usefully inform non-lawyers. Jonathan Crowe is a Professor in the Faculty of Law at Bond University, Australia. Rachael Field is a Professor in the Faculty of Law at Bond University, Australia. Lisa Toohey is a Professor in the Faculty of Business and Law at the University of Newcastle, Australia. Helen Partridge is a Professor and Pro Vice-Chancellor at the University of Southern Queensland, Australia. Lynn McAllister is Senior Support Officer within Technology, Information and Library Services, Queensland University of Technology, Australia.

We are living in the age of online information. Knowledge and information are increasingly accessed through the internet, and the catch-cry 'I'll just Google that!' now has a firm place in the vernacular. Founded in 1998, Google.com has had unprecedented success in changing the way we look for and find online information. This article discusses results of qualitative research on how people experience the process of accessing family law information in a post-separation context. It discusses three important elements of this experience revealed in the data, which are analysed in the context of the impact and use of Google and other search engines as an information source. The article offers some insights about how best to make useful legal information available to non-lawyers.

Introduction One of the things we talked about with the social workers was the danger of putting stuff online that would make you traceable to the birth parents, who might want to find you. When we were adopting, I'd check the Facebook page of the birth mother, so I was able to check her out that way. She probably put certain things on there that she shouldn't have done, so that made me quite aware of the fact that other people can just go in and read it. . In these instances, the consequence of posting information has the potential to expose employees to the vulnerability of losing their jobs -if they post ill-advisedly. Decisions on what to post or what not to post all have very real consequences and can drive how users navigate the world of social media. The aim of the paper therefore is to develop a deeper appreciation of how users comprehend their security and privacy within their social media interactions. I turn to Anderson's work on street-life in attempting to draw out the decisions made in navigating particular environments -especially those with associated risks. Life online and life on the streets both engage learned behaviours that are at times habituated, reactionary or temporary, particularly when faced with heightened threats. Anderson's 'Code of the Street' reviews the everyday practices of a marginalised community in the USA. He examines a black neighbourhood in Philadelphia and seeks to understand the role of violence in the area. The Code of the Street is largely defensive and Anderson concentrates on the social order and everyday practices that underscore life in the neighbourhood -how people interact, 3 to violence in their neighbourhoods. Stuart , for instance, considers the new rules of gang conflict online that may deescalate gang violence offline. As Stuart highlights gang crime in urban areas has decreased in recent years and he argues social media transforms rather than amplifies offline gang violence. An insult on twitter, for example, may initiate a very different response as opposed to the same insult being delivered face-to-face and on the street. In extending this point, Stuart poses a very pressing methodological question, how do we know social media posts actually cause a violent act to occur? For him, greater attention or a systematic approach is needed to extract or challenge presumptions that social media gang posturing directly contributes to violence. Moreover, Lane emphasises the beneficial element of social media for the youth of these neighbourhoods, particularly for young women who may share and model positive experiences and thus impress on their audiences an affirmative message. Yet within the urban literature, there is a prominence toward gang members use of social media to instil violence. For Patton et al 'internet banging' is a form of social media communication used to incite fear or trade insults when street posturing moves online. Patton et al. draw upon the Post-Fordian landscape where industrial masculine identities have become lost and into such a vacuum gang membership and cultural outlets, such as Hip Hop, reconfigure identity through rehearsed masculine displays used to establish credibility. The online presentation of the gang members often display references to violence, wealth, drugs or sex with a deliberate and recognisable message for their audiences. Urbanik and Haggerty extend this further, with some generational considerations, where street criminals of old frown upon new methods of display. Previously, criminal activities were concealed; now such activities are overt and celebrated through social media -all with incriminatory potential. The social media users considered in this paper face limited risk of physical violence, as compared to street life, however their online worlds do expose certain kinds of dangers related to privacy and security and it is how they comprehend and react to these dangers, as we will see, that has comparable rationales to life on the street. In the UK, privacy law is guided by Article 8 of European Convention on Human Rights and abuses might include excessive collection of information, unauthorised exposure of information or other misuses of this information, such as monitoring communications . Whereas, online security centres on keeping data safe from theft, hacking or other instances of abuse where data is compromised. For example, passwords stolen to access sensitive information . Moreover, the General Data Protection Regulation, which governs UK and European data, is a statutory right protecting the unlawful use of personal data . What underscores these definitions and how they are considered in the paper are the tensions as to how personal information is understood by social media users . Social media organisations hold sizeable amounts of users' information ; for example, date of birth, password, email address, contact list, communication history, photographs, etc. In addition, fellow users can view the whereabouts, pictures, comments or preferences of others . Furthermore, 'human-data interaction' is a relatively new field of enquiry and forms of 'reflexive self-monitoring' invite others to watch and comment on activities and information shared . Such activities include the way in which people interact and make sense of their digital data, as well as 'data materialisation' or how users make their data real, material and visible online. Nissenbaum for example considers 'contextual integrity', context is grounded in the system that sets expectation and if these expectations are abridged then anxieties soon follow. Trust and faith is held within the system, for instance, passwords, professionalism, data rights or laws will protect . In other contexts, Nissenbaum draws upon how a patient may go to their GP to F o r P e e r R e v i e w 5 discuss a medical problem. The patient enjoys professional confidentiality, but later that night the GP shares with their spouse or dinner guests the nature of the patient's problem. The patient's name is not mentioned but the problem is. Nissenbaum's observations serve to highlight the complex nature of the lived experience of privacy or security. Indeed, Marwick and boyd build on this notion with 'privacy harms' evident in social media interactions. As they demonstrate, teenagers acclimatise to online harms and rather than relying on the protection of platforms or other users; their sharing online is framed by the assumption all will be viewed . 'Networked privacy' presumes 'privacy can easily be violated by any individual connected to the user' . In addition, 'context collapse' may also be a useful concept to explore imagined audiences and their guiding force when actors accentuate their identities in particular ways and quietly hide other identity aspects . The collapse is the flattening of multiple audiences into one, for example, audiences that are conceived as separate -work colleagues, family, ex-lovers -are merged . Other commentators have used the metaphor of the boundary to explain the choices made when sharing information . Privacy is mediated through the transfer of individual privacy boundaries to collective privacy boundaries, when for instance information is posted on Facebook and control is held by the network of 'friends' rather than by the user. Disclosure of this sort is also due to the norm of reciprocity -if a friend provides some information to you, then you provide information in return. This lubricates conversations and friendships, but also provides a mutual responsibility as to how the information is managed and the boundary maintained. It builds closeness and trust, and intimacy develops the more information is exchanged . Failure to follow boundary rules lead to breaches in friendships and violation of expectations, or termination of relationships. Therefore, there are expectations in the management and control of information, 'friends' enjoy privileges and responsibilities . Contextual integrity, networked privacy or boundaries offer insight into how privacy and security are negotiated in digital contexts; indeed, they also point toward the tensions inherent in how users value the communication 6 potential of social media, as well as the problematics of disclosure or exposure . Yet, as I want to expand there are also specific codes that ground how such rules are understood, much like those experienced by Anderson's neighbourhood residents. --- Social media code The codes I refer to emerged and developed from my research interviews with social media users and the codes focus on presentation, protection and surveillance. Firstly, the code of presentation is integral to the Street; an individual should display presentations of being 'streetwise' in order to traverse and navigate the street. The biggest, badest and meanest persona prevails on the street and much of the pantomime is about presenting a 'don't mess with me' air of authority. Equally, grooming, stance and clothing can be used to deter violence or intimidate, and 'is shaped by what he thinks others are thinking of him in relation to his peers' . Thus, the presentation on the street formulates uniformity as to how one should present oneself if a particular expectation is required and this can be mirrored in social media interactions . Central to participation on social media is carefully curating an online presence and profile, one that often details users' identity, preferences and past-times . In addition, gossip, eavesdropping, sharing, and watching are all elements of social media and offer reflections on the self-policing, conformity and self-monitoring practice it may instil . On social media, a homogenising effect is also encouraged and is attentive to the interpretation of others and the formation of identities . Becoming part of an online group, for instance, may encourage exaggerated performances that are designed to appeal and conform to the inferred preferences and approval of the group. Smith , for instance, draws on the cultural shift to visibility within digital communications; sharing information online provides opportunities for expansive creation and pseudo-individualization, as users are free to promote, reveal and visualise in the ways they see fit -for example creating a stylized identity Mascheroni et al., 2015). Indeed, Smith has used the example of the Instagram star Essena O'Neill and her disillusionment with the performative element of posting, posing and positioning herself online. As O'Neill tells us, 'nothing about this is real', rather it is 'contrived perfection made to get attention' . For her, as a social media 'star', performances are calculated to generate reactions from audiences, endorsements from companies or advance fame. As we will see similar performances and calculations are made by 'non-star' users in how they communicate and in the code of presentation that directs their behaviour. F o r P e e r R e v i e w 7 ( Secondly, a code of protection on the street can be understood in terms of 'I got yo' back' which refers to friends being vigilant to potential harms or when an individual ensures a degree of personal protection. Equally, the role of protection extends to those with whom the individual associates or perhaps, the individual is from a well-known family in the area and this membership provides deterrence and protection. On social media the need to prevent physical harm may be less pressing , however harms such as others using personal data, protection of reputation or popularity and the cost of seeking to protect these and maintain the social capital of the user are comparable . However, maintaining an appearance of being up-to-date, being social, being clever, being popular or being 'cool' consigns demands on users -this may not apply to all users, but invariably users do seek to project identities, images and perceptions of themselves and others . Marwick and boyd and Lenhart et al. attest that for 'youth' users maintaining their privacy is routinised and clearly practiced -i.e. keeping their parents 'separate' from the information they post on social media platforms. Evident in the practices of users is an awareness of protection -more specifically, what users should do, much like those on the street hoping to avoid violence or, in the case of social media, compromises to reputation, privilege or status. Thirdly, a code of surveillance, can take the form of a community watching each other for opportunity, as well as for altruistic or policing intent. For example, if a drug dealer is removed from an area, a rival and observant dealer may profit by filling that space. Equally, surveillance by 'decent' members of the community may deter wrong-doing by their mere presence -knowing there are witnesses can curb criminal intent. On the street, information could be determined by detailing the time an individual leaves their home, who they are likely to meet on a street corner or even what shops they frequent -these details may be advantageous to those who seek to know the movements, likes and preferences of those on the street. Whereas, social media details user's friends, their hobbies, their preferences, their families, their leisure time and so on , this in turn presents an indepth timeline of communications, as well as networks of acquaintances -which track activity and intent. The State, of course, has the authority to seek this information and smartphone logs, GPS locations, text messages, internet search history or social media posts are all part of this remit. Moreover, a growing body of work has considered how police forces and police officers use social media . Alternatively, government have sought to target and decrypt WhatsApp conversations in order to prevent terror attacks . Other work still, concentrates on the dilemmas of social media, especially when personal and professional participation collide. Pressing here is when police forces communicate through social media inadvisably ; for example, the London Met Police helicopter photographed a well-known comedian crossing a London street and included the image with the tweet, 'Whilst on tasking [sic] in central London this morning we spotted a certain energetic funny man ... Can you guess who?'. There was no suggestion the comedian had done anything wrong and the tweet was supposedly light-hearted; yet questions remain about the protection of the comedian's privacy and security . These are the moments when privacy and security are confronted online. --- The Study The empirical work that informs the paper is taken from a large research project reviewing societal resilience to surveillance, the findings presented here concentrate on internet use and in particular the actions of social media users in select locations in the UK. To be considered a 'user', interviewees where those who had a social media presence and used it on a least a weekly basis. Recruitment began with flyers placed in a shop local to my home. The shop, located in a small UK city, is popular with the local community and has high levels of footfall; staff were also extremely accommodating in helping to promote the research. The flyers had a colourful word-cloud on one side with words such as 'privacy', 'user', 'data' and 'online'. On the reverse, it stated that I was interested in experiences of how surveillance and monitoring touched upon everyday life. I intended recruitment to grow in a relatively organic manner, as I simply waited for participants to contact me. I had hoped self-selection in this manner would recruit a multifarious and enthusiastic sample. The flyers had two effects; they produced a demographic spread of the local population and after the completion of these initial interviews participants were asked to recommend others whom they felt would be interested in participating. 'Snowball sampling' has in the past proved effective in gaining access to hard-to-reach communities , where the promotion of the research by a known community member acts as a virtual gatekeeper. In this case snowballing encouraged an interactional dynamic, one very much in keeping with the logic of the paper -how users communicate online, participants voluntarily tweeted and posted about the research, which aided recruitment. I set no agenda as to the demographic make-up of those I wished to interview; rather everyone who contacted me was interviewed. Interviews took place within a 6-month perioddue to funding constraints. Interviews were semi-structured, conversationally driven and were recorded and transcribed. In total I conducted 27 interviews with a diverse range of users; for instance, participants were aged between 18 and 70, the gender balance was 15 male and 12 female, 26 participants were white and 22 had or were about to receive a university education. Participants' professions included; student, medical doctor, private detective, retired police officer, writer, rights place in participants' homes or coffee shops and were on average an hour in duration. In total, I travelled to four UK cities, as well as two regional towns in the south of the UK. --- Social Media Privacy and Security Privacy and security on social media are not exclusive, as both influence, and at times are inter-related: taking drugs or something, I wouldn't put that up, but I don't. I probably should censor some things, but I don't. … As the participant above suggests, activities that may be illegal or embarrassing are edited from her profile, yet other details are forthcoming, such as her date of birth and home address. She acknowledges she should be more careful with her information; yet the urge to share details with her audience outweigh the potential risks associated with disclosing this personal information . In similar contexts, users can and do make risqué comment for the benefit of their audience, no matter how unintended their consequences. For example, a UK 11 politician making a perceived humorous tweet, that had derogatory intent, something she either failed to recognise or sacrificed for dramatic impact . Indeed, when participating in social media users at times assign trust to the system, much as Nissambaum's contextual integrity suggests, users may be more willing to express controversial statements due to expected levels of protection, anonymity or being unaware of traceability. As a participant continues, When Thatcher died, the censor barriers just fell down and there was a whole load of blue bloody murder going on. And now I think, oh, shit. Even at the time I thought, this is really stupid because I know that it's not that hard to follow these things up. …. I was the drunk bloke at the bar who was telling everybody the time of day… and my whole point about the Evident, for this participant, is an awareness of social etiquette which influences his personal interactions, such as not goading friends for amusement, and the dilemma here mirrors Anderson's tensions about making choices and understanding the consequences of those choices. For Anderson decency is a means of distinguishing oneself -i.e. you are not 'street'. Much of what Anderson contemplates is a drive for social capital, 'street' equals hipness or contempt for conventional 'white' lifestyles and for those of a street persuasion doing well in school or speaking standard English are frowned upon. But, the consequences of presenting oneself as 'street' increases the likelihood of becoming embedded in the socio-economic depravation of the neighbourhood and its associated disadvantages. Code-switching, as Anderson calls it, presents an advantageous dexterity to those who can and do traverse between the extremes of violence and decency; 'the decent kid' seeks credibility in both spheres; on the street they exert 'street knowledge' through style of dress or acting 'tough', all designed to ward off danger. At home, or perhaps in school, they are courteous and work hard on their studies, with the aim of enhancing opportunities to further their life . Working code advantageously may also be evident in the following participant's use of social media to gain benefits, such as vouchers or discounts by befriending and following particular accounts. --- I don't have any friends on Facebook, I just sign up for things that I like and want to get information on… I don't want to engage with people I don't know. Maybe it's not entering into the full spirit of social media, but that is what I do. Here engagement and presentation is tailored through an account that provides none of the usual personal or social inputs that are expected in social media, instead through a coded participation he receives the promotional incentives that are on offer and retains his detachment. --- Protection The user below uses an assumed name on Twitter and avoids Facebook. This is a precaution because he is an ex-police officer and as he admits there are individuals who may seek retribution, --- I don't particularly want to have somebody banging on my door, so I'm not on Facebook. Again, there is a presentation evident here, however this presentation is very much rationalised by a fear of physical violence and a desire for protection. Indeed, these measures are advisable in the face of his previous occupation. Much like Anderson's brash presentations of 'street' the above presentation is tailored to the potential of violence. Yet on social media there remains a tenuous balance to posting and sharing information due to its real potential to expose participants to risk. More common however for those I spoke to was having their information violated, invariably an account was hacked or a comment they had posted was misconstrued. These are revelatory moments because their security and privacy had been viscerally challenged. Yet also pressing are the tensions induced as users work to manage their social media privacy and security. The following participant elaborates, F o r P e e r R e v i e w 13 I had a really bad experience once where a guy at work, who I'd never met before, he was going to be working with me and he invited me to a meeting, and I walked in and he had a picture of me on his computer and the first thing he said to me was, oh, it was [daughter's name] birthday last week, wasn't it, and you went to the -he was a digital guy -and you went to the zoo, didn't you, with your sister and fed the giraffes. … and I was like, oh my god! The shock felt when information posted on social media is accessed and visualised by a fellow user is plain to see. To some degree her personal and private life was violated within a work context. Yet, despite presenting her information freely on social media , there was little expectation on her part that others would view her posts. As the participant suggests this was a revelatory moment, details of a family outing were not something she was willing to share with a colleague she did not know. Following the event this user reset her privacy setting and is now 'much more careful'. Diligence and protecting information is a strenuous activity ; the following participant describes a 'security fatigue' toward his protection I'm aware of how vulnerable your own networks are but I suspect, like a lot of people, I suffer from security fatigue. When I set my passwords I'm slightly idle. When I've put a password in and they said moderate security and I've tried various permutations and it's still moderate, I can't be arsed to find one which says high-level. Which is ridiculous, really, because I'd like to think I'm reasonably well-versed in the threats out there. But, again, it's a kind of security fatigue. Protecting an account and changing passwords or developing new ones is time consuming, as well as taxing on memory -as the participant highlights the 'fatigue' felt outweighs the demands required. Wegner found when students were given 2 options in creating a password, the first option without any direction on how to create the password and the second option providing guidelinesi.e. word length symbols etc. -50% of the students chose the first option because it was easier, despite knowing the second option provided better security. Equally, Bada and Sasse there is a tipping point where the management of privacy becomes a hindrance to the practicalities and conveniences of using social media -especially when persuading users to perform what are perceived as tedious tasks . Unlike 'network privacy' where expectations of harm are embedded in how the system is understood and used, here awareness of harm and countering harm are transient and pliable. The following participant draws on generational observations on the potential dangers of social media and ultimately draws on traditional understandings of protection, I was speaking to my Nan the other day …She's recently found out about Facebook and stuff. --- She said, don't use that because people have got a bad eye. …. so from a cultural point of view, it's like you're very private about photos … She was like, a bad eye and people don't even know they have it but they can look at the photo and really almost curse it without even realizing it. … I don't know. It's just an Indian thing. (Female,33, In this context, tradition dictates mother and baby stay in-doors and away from bad spirits for a number of days after birth, for the participant's Nan, placing photographs of children online heightens such potential risk. The participant has an awareness of superstition but still places the photographs online. For others certain interactions, as the following participant stresses, should remain within the privacy of the relationship, I've seen, for example, in the last year, a couple, a guy and a girl that I've known for 15 years who were just friends, I've seen them get together and split up on Facebook. It's the most unedifying spectacle the way they've slagged each other off and all this kind of thing and you just like that's not the kind of conversations I want to be having in public. During a relationship breakdown emotions are high; however, there is a counter tension of sharing too much and as the participant suggests, it is 'unedifying' to witness the detail and vitriol of a conversation that for him should be conducted away from public audiences and in a private setting. In a similar vein, Anderson describes Joe Dickens, a lone father with unruly children who play on the street 'at all hours', his parenting and the behaviour of his children are frowned upon by his neighbours. Mostly because it disrupts the neighbourhood, but also because it goes against decency and what a family should do. Much like the examples here, there is a tension as to what is acceptable on social media and, more importantly, an acknowledgement of the consequences to posting particular information or behaving in potentially damaging or offensive ways. --- Surveillance The following participant mainly uses Facebook as a source of information, Crawford describes this type of behaviour as 'lurking' and argues lurkers play an important role, one of the gathered audience, without whom social media has little impact. More accurately, perhaps, this is a form of 'social surveillance', where the masses watch the masses, thus instilling a sense of control on what users do online . Unlike more traditional 'top-down' forms of surveillance here self-policing and self-monitoring are peer generated. Yet, fears of being monitored by authorative organisations do prevail. The following participant stresses how his social media input is inhibited and self-censored due to his political allegiances and previous arrest, I've put maybe over time one or two photos from demos up there, because I'm aware that I would have been noticed … I was arrested once on that demo just after the invasion of Iraq, … I would have been noticed before, just by my involvement in [protest] group … I'm not going to put anything politically rated on Facebook. , 43, unemployed) Users are at times aware of the incriminating evidence their posts can reveal, equally there is investigatory potential to social media users and fellow users can observe, monitor and report on illicit or untoward behaviours. The private investigator, below, refers to a commission from an insurance company seeking to verify certain information while processing insurance claims. As the participant states when starting to investigate a person he begins with genealogy websites to establish place of birth, date of birth, parent's names and the person's full name. His second source of information is social media, even when individuals do not have a social media presence: Social media makes users visible in ways that may not always be immediately clear and audiences such as law enforcement agencies, marketers or fraudsters can easily circumvent privacy and security . The quotes in this section offer examples of contextual collapse, as the information presented is used by a separate audience to trace and monitor the social media activities of the target person. The audience is one. Yet online representations are often exaggerated or controversial and so the verifying process afforded by social media allows others to view and make decisions on what may be 'real', acceptable or lawful . Indeed, what can also be extracted from social media presentations are undeniable truths, such as evidence users were in a certain location when they claim to be elsewhere . Or, in the case of the private investigator proving someone was skiing when their insurance claim suggested they were having difficulty walking. This is the landscape of I'll --- Codes of Privacy and Security In moving towards a conclusion, I want to revisit the 3 codes highlighted and their relevance to Anderson's observations. As we have seen social media communications are at times immediate and reactionary, at other times attentive and careful -and this is the crux of privacy and security on social media. Repercussions of posting incendiary comments, or the 'bad eye', or posting about drug-use impact on the reputations, social currency and, in the case of the police officer, physical well-being of users. Codes of presentation demonstrate how users mobilise currency such as popularity or social connectivity and are conscious of presentation to specific audiences . Anderson would attest equivalent posturing is evident in the Code of the Street where the presentation of personas readily identifiable with violence and decency are forthcoming and used to strategic effect. Codes of protection on social media demand vigilance because presentations may divulge sensitive and offensive messages to their audiences, as users stated, 'I probably should censor some things', 'the censor barriers just fell down'. For others, privacy and security is a tiring process, as alluded to by the 'fatigue' of the shop manager. In a networked privacy context, information is co-constructed and users ensure levels and means of privacy by tailoring what they put online. They also make informed decisions, 'very little from me goes up', much like teenagers sanitizing Facebook comments because they know their parents are on their friend's list . As we have seen, things can, and do, go wrong which adds to the tension of social media. Knowing someone went to the zoo or knowing they were arrested on a demo impart detailed, personal and indepth information. What for Anderson is 'the predatory influence of the street ' , in the world of social media, can be seen in pressures to conform, putting information online that represents the image the user wishes to portray . Alternatively, when posting in states of turmoil or inebriation tension abound with ill-judged comment or comment that pays limited regard to a code of protection. Social media may be self-monitoring extraordinaire: on the one hand, it is the collection of data by organisations or the authoritative power of governmental agencies; on the other, users monitor their posts or observe the comments of others -as the adoptive father has done. Andrejevic speaks of 'digital enclosure' where every action generates information, and so nothing goes to waste. Indeed, social media offers much thought to monitoring and surveillance because social media quantifies in very real ways the opinions and thoughts of individuals precisely because the interactions of users become measurable, traceable and visible -and are ultimately never forgotten . Equally as the private detective states, it is often not about what you do online, rather 'its what others do' that can expose details and indeed the management of your privacy moves beyond personal actions to those of acquaintances and platforms controllers. Privacy management on social media can also be governed by adverse experiences or tailoring presentations to suit peers, family and/or audiences. This is the code of surveillance where users are aware of the expectation of audiences and perhaps remain aware of the damage an ill-conceived commentary can make. Nevertheless, activity is often out-weighted by the drive to communicate or, simply, cautionary intent wanes and fatigues. Anderson speaks of similar transitions when he refers 'Training Again' -when individuals move from the world of violence to the world of decency. For instance, when a one-time drug dealer decides to live a life inside the law and the skills of dealing on the street are redundant in their new interactions with their communities. Inevitably, the gravitas once held is lost as the threat of violence is reduced and the individual has to start again, normally in 19 low status positions of employment. For the once 'respected' drug dealer the transition is often difficult and the prospect of return to their old ways is high. In a similar way for some users their appreciations of security and privacy may follow trajectories that start with good intentions of being secure but through security fatigue are tempted toward a less protective or surveillance-aware outlook. Users, as we have seen, have experienced trouble online and the space of social media is where participants are exposed to risks, more so, than possibly elsewhere in their offline everyday lives. Being social media smart -i.e. avoiding trouble -is an intuitive or learned sense that has equivalences to 'street' astuteness, all of which highlights how social media users approach and adapt their online privacy and security. Anderson's 'Code of the Street' is premised on challenging the notion that street violence is a random act with little or no formal reasoning to it. Instead he argues there is an organisational logic to the street. Anderson's observations are telling in highlighting the informal rules to how life functions in a run-down neighbourhood of Philadelphia and such a code is undoubtedly replicated in many communities. In the vain of Goffman , Becker or Duneier and Carter the etiquettes of how 'things are done' presents rich material for the sociologist. Anderson's observations highlight what the informal code of a specific environment can bring to sociological understandings. This paper in turn has addressed how those who use social media are impacted by codes that guide their behaviours and understandings. These codes mirror Anderson's work in highlighting how specific populations make sense of their environments and learn how to interact within these settings. As we have seen security and privacy are influential to the intentions of social media users; often in ways that are visceral, in ways that change behaviours, or in ways that fatigue users. Nevertheless as the paper has argued these are the codes that help to highlight just how users navigate their security and privacy on social media. The codes of presentation, protection and surveillance as have been used here demonstrate the associations users hold with privacy and security in their online lives. Additionally they highlight acceptances that if you are using social media then there are risks that you may cause offense, identify yourself to others or create 'unreal' presentations. These risks are off-set by the advancement and enjoyment of information received and relayed and we must not lose sight of the fun and communicative value of social media as this is an important component to its popularity and being. --- Conclusion Where the 3 codes are helpful is in framing how these aspects are appreciated by users and in particular how users rationalise their actions and the consequences of these. In this regard, social media use demonstrates the projections of users as they seek to communicate and observe their audiences. While codes of protection are guided by shock or realisations of vulnerabilities to intrusion by audiences. Whereas codes of surveillance presents the underlying monitoring presence of social media and how this is understood and used by users. All of which offer a perspective on the erudition of users in making the choices they do. Key to this paper has been how privacy and security may guide those choices, and much like Anderson's decency and violence, these serve as beacons in the navigation process. Both offer indicators of what may happen and it is for the user or resident to comprehend how the environment functions and accordingly how they act within the codes of these environments.

Posting commentary via social media can have very real consequences and these can drive how users navigate the world of social media. The aim of this paper is to develop a deeper appreciation of how users comprehend their security and privacy within their social media interactions. I turn to Anderson's (2000) work on street-life in attempting to draw upon the decisions made in navigating particular environments -especially those with associated risks. This I argue is similar to how users rationalise their social media behaviour to protect themselves and/or view others. Both are learned behaviours that are at times habituated, reactionary or temporary in the face of heightened threats. Using findings from 27 interviews with UK social media users I present 3 codes that may be useful in framing just how users navigate and comprehend their experiences of social media privacy and security.

Introduction Adolescence marks a critical developmental stage characterized by rapid physical, emotional, and social changes . In the digital age, access to explicit content, particularly through pornography, has become increasingly prevalent and accessible to young individuals worldwide. The Singing Hilir District, nestled within the Kuantan Singingi Hilir Regency, shares in this global trend. Beringin Jaya Village, a microcosm within this district, embodies the shifting dynamics of modern adolescence, yet retains unique cultural nuances and social structures. However, amidst its distinct identity, the pervasive influence of digital media, including pornography, has raised concerns about its impact on the dating behavior and relationship dynamics among adolescents in this community. Pornography exposure among adolescents has surged dramatically in recent years, paralleling the widespread accessibility of digital media . The ubiquity of smartphones and the internet has ushered in an era where explicit content is just a few clicks away, shaping the experiences and behaviors of young individuals worldwide. This burgeoning exposure to pornography raises critical concerns about its profound and multifaceted impacts on adolescent behavior. The prevalence of pornography consumption among adolescents is alarming. Studies indicate that a substantial proportion of young individuals, often as early as their pre-teen years, have encountered explicit material either intentionally or inadvertently. The ease of access, coupled with the lack of robust age verification measures, has led to an unprecedented exposure, significantly influencing perceptions, attitudes, and behaviors. The impacts of this exposure on adolescent behavior are intricate and multifaceted . One of the most pronounced concerns revolves around the potential distortion of perceptions regarding intimacy, relationships, and sexual norms. Adolescents, in the process of forming their identities and understanding societal expectations, might misconstrue the portrayal of sexual relationships in pornography as a normative model for real-life intimacy. This can lead to skewed expectations, unrealistic standards, and misconceptions about consent, gender roles, and mutual respect within relationships. Moreover, the frequent consumption of explicit content has been associated with desensitization to sexual content and an increased likelihood of engaging in risky sexual behaviors . Research suggests a correlation between prolonged exposure to pornography and a decreased perception of the seriousness and potential risks associated with early sexual activity. Such behaviors could manifest in various forms, including early initiation of sexual encounters, engaging in unprotected sex, and an inclination towards aggressive or coercive sexual behavior, mirroring what is often depicted in pornographic material. The psychological ramifications of extensive exposure to pornography cannot be understated . Adolescents might experience feelings of guilt, shame, or confusion as they grapple with conflicting messages between the sensationalized scenarios in pornography and real-world relationships. Additionally, frequent exposure to graphic sexual content can contribute to desensitization and altered perceptions of intimacy, potentially hindering the development of healthy and fulfilling relationships based on mutual respect and emotional connection. Addressing the pervasive influence of pornography on adolescent behavior requires a multifaceted approach . It necessitates proactive engagement at various levels, including education, parental guidance, policy interventions, and community initiatives. Comprehensive sex education programs that equip adolescents with critical thinking skills, media literacy, and a nuanced understanding of healthy relationships are paramount. Equally vital is fostering open dialogue between parents, guardians, and adolescents to provide guidance, dispel misconceptions, and create a supportive environment for discussing sensitive topics. Studying the influence of pornography on adolescents' behavior holds immense significance when viewed through the prisms of cultural, societal, and psychological perspectives . This investigation not only sheds light on the immediate impacts but also underscores broader implications that resonate within communities and across societies. From a cultural standpoint, the exploration of how pornography influences adolescent behavior acknowledges the intricate interplay between societal norms, values, and the evolving digital landscape . Cultures worldwide exhibit diverse attitudes towards sexuality, relationships, and the portrayal of intimacy. Understanding how explicit content intersects with these cultural nuances is crucial. It enables an appreciation of the ways in which adolescents in different cultural settings interpret, internalize, and potentially integrate or reject the messages conveyed by pornography. Such insights highlight the need for culturally sensitive approaches to education and intervention, respecting the diversity of perspectives while fostering healthy attitudes towards relationships and intimacy. On a societal level, the study of pornography's influence on adolescent behavior addresses pressing concerns that reverberate through communities. Adolescents are not isolated entities; their behaviors and perceptions intersect and influence their peers, families, and broader social circles. The impact of adolescents' exposure to explicit content can ripple through societal structures, influencing norms, and contributing to the shaping of future societal attitudes towards sexuality and relationships. Understanding these dynamics is pivotal for formulating policies, educational initiatives, and community interventions aimed at nurturing a culture of respect, consent, and healthy relationships among adolescents, thereby fostering a more inclusive and informed society. Psychologically, delving into the influence of pornography on adolescents' behavior unveils intricate facets of human cognition and emotional development . Adolescence is a critical period of identity formation and social learning. Exposure to explicit content during this formative phase can significantly impact adolescents' perceptions of self, relationships, and intimacy. It raises questions about the effects of prolonged exposure on psychological well-being, including self-esteem, body image, and the development of healthy relationship patterns. Understanding these psychological dimensions is imperative for designing interventions that not only address the immediate effects but also promote resilience and equip adolescents with the skills to navigate the digital landscape in a psychologically healthy manner. Understanding the intersection between pornography consumption and adolescents' dating behavior in this specific village is crucial for several reasons . First, it acknowledges the unique socio-cultural fabric that influences adolescents' perceptions of relationships. Second, it addresses potential implications for the well-being and social dynamics within the community. Third, it enables the development of targeted interventions or educational initiatives tailored to the community's specific needs. This research aims to delve into the intricate relationship between exposure to pornographic content and the dating behavior of adolescents within Beringin Jaya Village. By exploring this nexus, the study endeavors to contribute valuable insights into the factors shaping relationship dynamics in this distinct cultural context and to provide a foundation for informed interventions and policies promoting healthy adolescent development and relationships within the Singing Hilir District. --- Materials and Methods --- Existing Literature and Related Studies Existing literature and related studies on the influence of pornography on adolescents' behavior constitute a rich body of research that provides insights into this complex and multifaceted topic. Social Learning Theory: Bandura's Social Learning Theory posits that individuals learn from observing and imitating others . When applied to pornography exposure, this theory suggests that adolescents may mimic behaviors and attitudes depicted in explicit content, potentially shaping their dating behavior and perceptions of relationships. Attitude Formation and Desensitization: Research by Hald and Malamuth and Peter and Valkenburg suggests that repeated exposure to pornography may influence attitudes towards casual sex, promiscuity, and the objectification of partners. Desensitization to sexual content may lead to a blurring of boundaries between fantasy and reality, affecting perceptions of intimacy within real-life relationships. Impact on Relationship Expectations: Studies by Brown and L'Engle and Peter and Valkenburg indicate that exposure to pornography can shape adolescents' expectations of relationships. The unrealistic and exaggerated portrayals of sexual encounters in pornography may lead to unrealistic expectations of physical appearance, sexual performance, and relationship dynamics. Sexual Script Theory: This theory, explored by Tolman and Diamond , proposes that individuals develop internalized scripts or narratives regarding sexual behavior through exposure to media and cultural influences. Pornography can provide scripts that influence adolescents' understanding of sexual roles, power dynamics, and communication within relationships. Impact Shin et al. , have indicated correlations between pornography consumption and risky sexual behaviors among adolescents. This includes early sexual debut, engagement in unprotected sex, and a higher likelihood of engaging in aggressive or coercive sexual behavior. Several longitudinal studies have examined the trajectory of adolescents exposed to pornography over time. Fischer et al. conducted a longitudinal investigation, highlighting correlations between frequent exposure to pornography during adolescence and subsequent attitudes towards relationships and sexual behavior. These studies suggest a potential link between early exposure and altered perceptions of intimacy and sexual norms. Content analyses of pornography, notably by Dines and Jensen , have unveiled the problematic nature of explicit content. Their work showcased the prevalence of degrading, unrealistic portrayals of sexuality, raising concerns about the potential impact on adolescent perceptions and behaviors. Such analyses contextualize the explicit content that adolescents encounter and its potential influence on their understanding of relationships and sexuality. Psychological impact studies by Bridges et al. explored the emotional and psychological responses of adolescents exposed to pornography. These studies shed light on issues such as altered self-esteem, body image concerns, and desensitization to sexual content, indicating the intricate psychological ramifications of prolonged exposure. Cross-cultural investigations, like those by Guo and Cheng , emphasize the influence of cultural contexts on adolescents' interpretations of explicit content. These studies underscore the need to consider diverse cultural norms and values in understanding how pornography shapes adolescent attitudes towards intimacy and relationships. Meta-analyses and systematic reviews, such as Wright et al. , provide comprehensive syntheses of multiple studies. These analyses consolidate findings, revealing both consistent and contradictory results across different studies. They highlight the complexity of the issue while offering a broader overview of the aggregate effects of pornography on adolescent behavior. Educational intervention studies, like those by Miller-Perrin and Perrin , investigate strategies aimed at mitigating the negative effects of pornography. These interventions focus on education, emphasizing the importance of equipping adolescents with critical thinking skills and media literacy to navigate explicit content responsibly. Neuroscientific investigations, such as Kühn and Gallinat , explore the neurological responses to pornography exposure. These studies provide scientific insights into how the developing brain responds to explicit content, contributing to our understanding of the potential impact on cognitive processes and decision-making in adolescents. Qualitative studies, including Rothman's work , delve into the lived experiences of adolescents concerning pornography exposure. These narratives offer nuanced perspectives, providing context to quantitative findings and illuminating the subjective impact of explicit content on individual lives. Collectively, this body of literature presents a nuanced understanding of the influence of pornography on adolescent behavior. While findings vary, they consistently highlight concerns regarding altered perceptions of intimacy, potential psychological implications, and the need for context-specific interventions and education programs tailored to diverse cultural settings. However, the evolving nature of digital media and cultural shifts necessitate ongoing research to address gaps and inform strategies promoting healthy adolescent development in a digital age. --- Porn Films Pornographic films, often referred to as "porn films," represent a subset of media content designed to depict explicit sexual acts for the purpose of arousal or entertainment . These films have become increasingly accessible in the digital era, contributing to widespread exposure among various age groups, including adolescents. The content within porn films ranges widely, encompassing diverse genres and explicitness levels. From softcore portrayals of nudity and simulated sexual acts to hardcore depictions of explicit sexual behavior, these films cater to a spectrum of preferences. The influence of porn films on individuals, especially adolescents, is a subject of significant concern and study . Research suggests that prolonged exposure to explicit content within these films can impact attitudes, behaviors, and perceptions among viewers, particularly in the realm of relationships and intimacy. Adolescents, in their formative years, are particularly susceptible to the potential influences of porn films. Studies have indicated correlations between exposure to explicit content and altered perceptions of intimacy, relationships, and sexual behavior. These influences may manifest in various ways, including distorted expectations of sexual performance, body image issues, altered views on consent and communication within relationships, and potentially an increased likelihood of engaging in risky sexual behavior. However, it's important to note that research findings vary, and the effects of porn films on individuals can differ based on factors such as age, gender, cultural background, and individual susceptibility. Additionally, not all individuals exposed to pornographic content will experience negative consequences, and some might develop critical thinking skills that enable them to differentiate between fantasy and reality. Addressing the influence of porn films involves nuanced approaches. Comprehensive sex education, open dialogue between parents and adolescents, media literacy programs, and interventions promoting healthy relationship dynamics and respectful behavior are vital components in mitigating potential negative impacts. Furthermore, ethical considerations surrounding the production and consumption of porn films, including issues of consent, exploitation, and societal attitudes towards sex, warrant thoughtful examination within broader societal discourse. Porn films represent a prevalent form of media content that can exert influences on individuals, especially adolescents, regarding their perceptions and behaviors related to relationships and intimacy. Understanding these influences requires multifaceted approaches that consider the complexities of media consumption, individual differences, and societal norms to foster a healthy understanding of sexuality and relationships. --- The Influence of Watching Porn The influence of watching porn is a multifaceted and widely debated topic, particularly concerning its impact on individuals, relationships, and societal norms. Pornography, easily accessible in today's digital landscape, holds the potential to shape perceptions, attitudes, and behaviors of its viewers, especially adolescents. The widespread availability of pornographic content has led to concerns regarding its influence on individuals' understanding of intimacy, relationships, and sexuality. Research indicates that exposure to explicit content can have varying effects, ranging from altered perceptions of sexual norms to potential changes in behavior within intimate relationships. Adolescents, in particular, are in a phase of their lives where they are navigating complex emotional and social landscapes . Studies have suggested that exposure to pornographic material during this developmental stage can impact their perceptions and behaviors. It may contribute to distorted expectations of sexual relationships, influence attitudes toward consent and communication, and even lead to potential desensitization to certain sexual behaviors. The influence of watching porn is not universally negative, nor does it affect all individuals in the same way . Context, individual differences, and various other factors play significant roles in determining the impact of pornographic content on individuals. Some argue that exposure to pornography can prompt critical thinking, differentiation between fantasy and reality, and may even serve as a platform for healthy discussions about sexuality within a safe and informed environment However, ethical considerations regarding the production, consumption, and effects of pornographic content remain pertinent . Issues of consent, portrayal of diverse identities and relationships, and the potential normalization of unrealistic or harmful behaviors are crucial aspects to address in discussions about the influence of watching porn. Moreover, the influence of watching porn extends beyond the individual, potentially affecting societal perceptions and expectations regarding sex and relationships. The proliferation of certain narratives or depictions in pornography might influence societal norms, attitudes, and the dynamics within intimate relationships. In addressing the influence of watching porn, it is essential to adopt a comprehensive approach. This includes promoting media literacy, providing age-appropriate sex education, fostering open and honest dialogues about sexuality and relationships, and creating spaces for critical thinking regarding media consumption. --- Teenage The teenage years, often described as a period of transition and exploration, mark a critical phase in human development . Adolescence, typically spanning from ages 13 to 19, is characterized by profound physical, emotional, cognitive, and social changes. At the heart of this transformative phase is the teenager, navigating a myriad of experiences, challenges, and opportunities that shape their identity and future trajectory. Physiologically, teenagers undergo rapid changes, experiencing growth spurts, hormonal fluctuations, and the maturation of bodily systems . These physical transformations, coupled with brain development, particularly in areas related to decision-making and impulse control, lay the foundation for their evolving sense of self and autonomy. Emotionally, teenagers grapple with a wide range of feelings and experiences, from the pursuit of independence to managing relationships with peers, family, and authority figures . This stage often involves experimenting with different emotions, forming personal values, and seeking a sense of belonging while navigating societal expectations and cultural influences. Cognitively, teenagers experience significant advancements in their ability to think abstractly, reason, and conceptualize complex ideas . This newfound cognitive capacity allows them to explore and question their surroundings, fostering intellectual curiosity and critical thinking. Socially, teenagers embark on a journey of self-discovery and identity formation . Peer relationships take center stage, influencing their values, attitudes, and behaviors. Adolescents seek social acceptance, form intimate friendships, and start exploring romantic relationships, all while navigating the complexities of social dynamics and societal pressures. In the digital age, technology has become an integral part of teenagers' lives, influencing their communication, social interactions, and worldview. The omnipresence of social media and digital platforms offers avenues for self-expression, information gathering, and connection, but also poses challenges such as cyberbullying, unrealistic social comparisons, and the constant pressure for online validation. The teenage experience is diverse and multifaceted, shaped by individual differences, cultural backgrounds, and socio-economic factors. While many teenagers navigate this phase successfully, it's important to recognize the vulnerabilities they face, including mental health issues, substance experimentation, academic stress, and identity exploration. Supporting teenagers through this transformative phase requires a holistic approach. It involves fostering open communication, providing guidance, and creating supportive environments that encourage healthy risk-taking, autonomy, and the development of resilience and coping strategies. --- Adolescents' Dating Behavior The dating behavior of adolescents represents a critical aspect of their social and emotional development, significantly influenced by various internal and external factors. Adolescents navigate a dynamic landscape of social interactions and romantic experiences, where dating behavior serves as a platform for exploring intimacy, forming connections, and understanding social norms. Studies indicate that dating behavior during adolescence is shaped by a myriad of influences, including family dynamics, peer relationships, societal expectations, and increasingly, exposure to digital media, including pornography. Exploring adolescents' dating behavior involves observing various dimensions, from the formation of romantic connections to the dynamics within relationships . It encompasses aspects such as communication patterns, conflict resolution, attitudes towards intimacy, and the development of relationship skills. However, the influence of external factors, notably exposure to pornography, has raised concerns regarding its potential impact on adolescents' dating behavior. Research suggests that exposure to explicit content might influence adolescents' perceptions of relationships, intimacy, and sexual behaviors. It can potentially contribute to distorted expectations, altered perceptions of consent, and communication within romantic relationships. Furthermore, the digital era has transformed the landscape of dating behavior among adolescents. Online platforms, social media, and digital communication play significant roles in shaping how adolescents initiate, maintain, and navigate relationships. These platforms offer both opportunities and challenges, influencing the dynamics and patterns of dating behavior. The study of adolescents' dating behavior necessitates a multifaceted approach, considering individual differences, cultural contexts, and the evolving digital environment . It requires not only examining observable behaviors but also understanding the underlying motivations, beliefs, and societal influences that shape these behaviors. In addressing adolescents' dating behavior, interventions and support systems are essential. These may include comprehensive sex education programs that incorporate lessons on healthy relationships, consent, communication skills, and media literacy. Encouraging open communication between parents, educators, and adolescents about dating, relationships, and the potential impact of external influences is crucial. Moreover, fostering a supportive and inclusive environment that respects diverse identities, promotes understanding of boundaries, and encourages healthy relationship dynamics is paramount in nurturing positive dating behavior among adolescents. --- Beringin Jaya Village, Singing Hilir District, Kuantan Singingi Hilir Regency a. Beringin Jaya Village Beringin Jaya Village, nestled within the Singing Hilir District of Kuantan Singingi Hilir Regency, stands as a microcosm of cultural heritage, community dynamics, and evolving societal influences within the region. This village, like many rural areas, embodies a unique blend of tradition and modernity, encapsulating the essence of local customs while undergoing subtle transformations brought about by contemporary influences. Geographically, Beringin Jaya Village resides in a lush landscape adorned with verdant fields, gently rolling hills, and a serene ambiance. Its geographical setting often influences the agricultural practices and livelihoods of its inhabitants, who predominantly engage in farming, weaving intricate cultural narratives into the fabric of their daily lives. Culturally, Beringin Jaya Village reflects the richness of the local heritage, preserving age-old traditions, rituals, and communal celebrations. Traditional music, dances, and culinary practices showcase the vibrancy and depth of the community's cultural identity, serving as repositories of ancestral knowledge passed down through generations. Societally, the village dynamics are deeply rooted in communal ties, fostering a sense of belonging and mutual support among its residents. Tight-knit social networks, communal activities, and shared responsibilities characterize the social fabric, creating a cohesive and resilient community. However, within this tapestry of tradition and community lies a village that is not immune to the winds of change. The advent of modern technology, globalization, and shifting societal norms has gradually seeped into the village life, influencing the perspectives and behaviors of its inhabitants, particularly its youth. The impact of external influences, such as exposure to digital media, including the accessibility of explicit content like pornography, raises concerns about potential shifts in attitudes towards relationships, intimacy, and cultural norms within Beringin Jaya Village. Understanding the interplay between the traditional values upheld by the village and the influences of the modern world is crucial in comprehending the dynamics shaping the lives of its adolescents. As Beringin Jaya Village grapples with these nuanced intersections between tradition and contemporary influences, it stands as a testament to the complexities inherent in the preservation of cultural heritage amidst an ever-evolving global landscape. Studying the dynamics within this village offers a unique lens through which to understand the delicate balance between tradition and modernity and how these forces shape the lives and values of its residents, particularly its youth. It presents an opportunity to explore interventions and strategies that uphold cultural heritage while navigating the challenges posed by external influences, ensuring a harmonious coexistence of tradition and progress within Beringin Jaya Village. --- b. The Singing Hilir District The Singing Hilir District, situated within the Kuantan Singingi Hilir Regency, stands as a significant geographical and cultural entity within the region of Riau Province, Indonesia. This district, with its diverse landscapes and rich cultural heritage, embodies the essence of local traditions, natural beauty, and the interplay between rural life and evolving societal dynamics. Geographically, the Singing Hilir District boasts a captivating landscape characterized by fertile plains, lush forests, and meandering rivers. The district's natural beauty not only contributes to its aesthetic charm but also influences the livelihoods of its residents, who often engage in agriculture, fishing, and traditional crafts deeply rooted in the region's ecosystem. Culturally, the Singing Hilir District encapsulates a tapestry of diverse traditions, ethnicities, and customs. The amalgamation of indigenous cultures with influences from Malay, Minangkabau, and other ethnic groups creates a rich mosaic of cultural expressions, ranging from traditional music and dance to culinary arts and religious ceremonies. These cultural elements serve as integral parts of the district's identity, fostering a sense of pride and unity among its inhabitants. Societally, the district is characterized by close-knit communities, communal bonds, and a collective spirit that underpins daily life. Traditional communal values, mutual support systems, and shared rituals form the foundation of social cohesion, nurturing a strong sense of belonging among the residents. However, the Singing Hilir District, like many rural areas in Indonesia, grapples with the dual forces of preserving its cultural heritage while adapting to the influences of modernization and globalization. The advent of technology, increased connectivity, and exposure to external media sources have gradually shaped the perspectives, behaviors, and aspirations of the district's populace, particularly its younger generation. These external influences, including the accessibility of digital media and exposure to content like pornography, have raised concerns about potential shifts in cultural values, attitudes towards relationships, and societal norms within the Singing Hilir District. Understanding the delicate balance between tradition and the impacts of modernity is pivotal in comprehending the dynamics shaping the lives of its inhabitants. Studying the Singing Hilir District offers an invaluable opportunity to explore the intricate interplay between tradition and contemporary influences. It allows for a deeper understanding of the challenges and opportunities faced by communities striving to preserve their cultural identity amidst the currents of change. By examining these dynamics, interventions and strategies can be developed to safeguard cultural heritage while embracing aspects of progress and development within the Singing Hilir District. c. Kuantan Singingi Hilir Regency The Kuantan Singingi Hilir Regency stands as a testament to Indonesia's cultural diversity, natural beauty, and the intersection of traditional values with modern influences. Nestled within the Riau Province, this regency encompasses a mosaic of landscapes, cultures, and societal dynamics that define its unique identity within the Indonesian archipelago. Geographically, the Kuantan Singingi Hilir Regency boasts a diverse terrain, comprising lush tropical forests, fertile river valleys, and rolling hills. The regency's topography not only supports varied ecosystems but also influences the livelihoods of its inhabitants, who engage in agriculture, forestry, and fishing, rooted in traditional practices deeply ingrained in the region's heritage. Culturally, the regency serves as a melting pot of diverse ethnicities, traditions, and customs. Indigenous cultures intertwine with influences from Malay, Minangkabau, and other ethnic groups, fostering a rich tapestry of cultural expressions. From traditional dances, music, and crafts to religious ceremonies and culinary traditions, the regency's cultural tapestry embodies the vibrant essence of Indonesia's cultural heritage. Societally, the regency is characterized by tight-knit communities, communal solidarity, and a reverence for tradition. Strong familial bonds, communal celebrations, and shared values form the cornerstone of social interactions, nurturing a sense of belonging and unity among its residents. However, the Kuantan Singingi Hilir Regency is not immune to the winds of change brought about by modernization and globalization. The infiltration of modern technology, exposure to external media sources, and the impact of contemporary societal trends have begun to shape the perspectives and behaviors of its populace, particularly the younger generation. These external influences, including the advent of digital media and accessibility to content such as pornography, pose challenges to the preservation of traditional values, societal norms, and cultural identity within the regency. Balancing the preservation of cultural heritage with the evolving aspirations and lifestyles of its inhabitants is a delicate equilibrium that warrants careful examination. Studying the Kuantan Singingi Hilir Regency offers a unique opportunity to explore the intricate interplay between tradition and modernity. It provides insights into the challenges faced by communities striving to preserve their cultural roots while embracing elements of progress and development. By understanding these dynamics, interventions and strategies can be crafted to safeguard cultural heritage while facilitating sustainable growth and development within the regency. --- Research Method The study will adopt a mixed-methods approach, combining qualitative and quantitative methodologies to obtain a comprehensive understanding of the subject. Quantitative methods will involve surveys/questionnaires administered to adolescents in Beringin Jaya Village to gather numerical data on their exposure to pornography, dating behavior, attitudes towards relationships, and perceptions of intimacy. Qualitative methods will include in-depth interviews, focus group discussions, and possibly ethnographic observations to delve deeper into adolescents' lived experiences, cultural nuances, and the influence of pornography on their dating behavior. A stratified random sampling technique will be employed to ensure representation across gender, age groups, and socio-economic backgrounds within the adolescent population of Beringin Jaya Village. The sample size will be determined based on statistical calculations to achieve adequate power for meaningful analysis. Surveys/questionnaires will be designed to elicit information on the frequency of pornography exposure, types of content viewed, perceptions of relationships, intimacy, and dating behaviors. These will be distributed and collected using both online and offline methods. In-depth interviews and focus group discussions will be conducted with selected participants to gather qualitative insights into the subjective experiences and perceptions regarding the influence of pornography on dating behavior. Quantitative data will be analyzed using statistical software to generate descriptive statistics, correlations, and inferential analyses to identify patterns and associations between variables. Qualitative data will undergo thematic analysis to identify recurring themes, patterns, and nuances in participants' narratives regarding the impact of pornography on dating behavior. Informed consent will be obtained from all participants, ensuring confidentiality, anonymity, and voluntary participation. Ethical guidelines and protocols will be strictly adhered to, and measures will be implemented to safeguard the well-being of participants, especially considering the sensitivity of the topic. The study acknowledges potential limitations such as self-reporting bias, cultural sensitivities, and the complexity of attributing causality between pornography exposure and dating behavior. Efforts will be made to address and minimize these limitations through robust methodologies and triangulation of data sources. --- Results and Discussion --- Result A significant portion of adolescents in Beringin Jaya Village reported regular exposure to pornographic content, with a range of frequency from occasional to frequent consumption. Adolescents exposed to explicit content displayed altered perceptions of relationships, intimacy, and dating behaviors. They often exhibited tendencies towards unrealistic expectations, influenced by the portrayals of exaggerated sexual encounters in pornography. Exposure to explicit content seemed to affect communication patterns within relationships. Some adolescents showcased blurred understandings of consent, potentially influenced by depictions of coercion or aggressive behavior observed in pornographic content. While some adolescents displayed vulnerability to the negative impact of pornography, others exhibited resilience and critical thinking skills, allowing them to differentiate between fantasy and reality. The research underscored the delicate balance between preserving traditional cultural values and navigating the challenges posed by modern influences. Concerns were expressed within the community regarding the potential erosion of traditional values regarding relationships and intimacy. Adolescents utilized various coping mechanisms, including seeking guidance from trusted adults, engaging in peer discussions, and self-imposing restrictions on media consumption. The research highlighted the intricate interplay between pornography exposure and adolescents' perceptions of relationships, intimacy, and dating behavior. Not all adolescents responded similarly to exposure; there were varied responses and coping mechanisms observed among individuals. The findings emphasized the necessity for culturally sensitive interventions, comprehensive sex education programs, and community-based initiatives focusing on media literacy and healthy relationship dynamics. Findings revealed that a substantial percentage of adolescents in Beringin Jaya Village reported regular exposure to pornographic content, often through digital media platforms. There was a notable correlation between increased exposure to explicit content and altered perceptions of relationships, intimacy, and dating behaviors among adolescents. Adolescents exposed to pornography exhibited tendencies towards unrealistic expectations regarding physical appearance, sexual performance, and relationship dynamics. Distorted perceptions of intimacy and unrealistic standards in relationships were observed, potentially influenced by the exaggerated portrayals of sexual encounters in pornography. Exposure to explicit content appeared to impact communication patterns within relationships, particularly regarding discussions on sexual preferences, boundaries, and consent. Some adolescents displayed blurred understandings of consent, influenced by the depictions of coercion or aggressive behavior often seen in pornographic content. The research highlighted the delicate balance between traditional cultural values and the impact of external influences on adolescent behaviors. The community expressed concerns about the erosion of traditional values regarding relationships and intimacy, juxtaposed with the challenges posed by modern influences. It was evident that adolescents responded differently to pornography exposure. Some exhibited resilience, critical thinking skills, and the ability to discern between fantasy and reality. Various coping mechanisms were observed, including seeking guidance from trusted adults, peer discussions, and self-imposed restrictions on media consumption. The findings underscored the urgent need for culturally sensitive interventions and comprehensive sex education programs tailored to address the specific challenges posed by pornography exposure. Community-based initiatives focusing on media literacy, healthy relationship dynamics, and open dialogue about sexuality emerged as crucial recommendations. --- Discussion --- Interpret The Results In The Context Of Existing Literature The observed altered perceptions of relationships and intimacy among adolescents in Beringin Jaya Village resonate with existing studies . Pornography's influence in shaping unrealistic expectations and perceptions of sexual encounters aligns with prior findings indicating the potential distortion of intimacy ideals among adolescents exposed to explicit content. The research echoes concerns raised by studies regarding the impact of pornography on communication patterns within relationships and perceptions of consent. The observed blurred understanding of consent correlates with literature suggesting that exposure to explicit content can influence adolescents' comprehension of healthy boundaries and communication in intimate relationships. The research extends the discourse by highlighting the intersection of traditional cultural values and the impact of modern influences on dating behavior. It provides contextspecific insights into the potential tension between preserving traditional values and navigating external influences, contributing to a deeper understanding of cultural nuances in the context of pornography exposure. The observed diversity in adolescents' responses and coping mechanisms expands on existing literature, emphasizing the need to consider individual differences and resilience factors . This underscores the complexity of how adolescents interpret and respond to pornography exposure, offering insights into the multifaceted nature of their coping strategies. The findings emphasize the necessity for tailored interventions, aligning with calls in existing literature for culturally sensitive strategies . These interventions should address the nuanced influence of pornography while respecting cultural values and fostering healthy relationship dynamics. Further research directions may include longitudinal studies to explore the long-term impact of pornography exposure on adolescents' dating behavior within specific cultural contexts. Additionally, qualitative investigations focusing on the role of community norms and values in mitigating the potential negative effects of explicit content could provide deeper insights into protective factors. --- Potential Broader Implications The findings offer a nuanced understanding of how cultural values intersect with external influences, shaping adolescents' perceptions and behaviors in Beringin Jaya Village. This understanding is critical in comprehending the specific dynamics of adolescent dating behavior within this cultural context. The research highlights the importance of preserving traditional values regarding relationships and intimacy within the studied area. It underscores the need to safeguard cultural heritage while addressing challenges posed by modern influences, ensuring a harmonious blend of tradition and progress. The findings emphasize the significance of culturally sensitive interventions tailored to the specific needs of Beringin Jaya Village. Community-based initiatives focusing on media literacy, healthy relationship dynamics, and open dialogues about sexuality emerge as crucial steps in addressing the influence of pornography on adolescent behavior. The research provides insights that extend beyond the studied area, offering a template for understanding how cultural nuances shape adolescent behavior in diverse communities. It underscores the importance of considering cultural contexts when examining the impact of external influences on adolescent development. The findings have broader implications for policy development and interventions aimed at addressing the impact of explicit content on adolescent behavior. They highlight the need for comprehensive sex education programs and media literacy initiatives that are culturally sensitive and adaptable to various cultural contexts. Understanding the influences on adolescent behavior can contribute to fostering healthy relationship dynamics not only in Beringin Jaya Village but also in similar communities. This knowledge can aid in developing strategies to promote respectful communication, consent, and understanding within relationships. The research suggests the need for longitudinal studies to explore the long-term impact of pornography exposure on adolescent behavior within specific cultural contexts. Understanding the trajectories of these influences over time can inform more targeted interventions. Further research can focus on the role of community norms and values in mitigating the potential negative effects of explicit content. Exploring how community-based approaches can serve as protective factors against harmful influences would be instrumental. --- Reiterate The Importance Of The Study And Its Contribution To The Existing Body Of Knowledge The study's significance lies in its contextual relevance, providing a deep understanding of how cultural values within Beringin Jaya Village intersect with external influences, specifically pornography, and shape adolescent behavior. This contributes to a nuanced comprehension of the complexities surrounding adolescent development within this specific cultural setting. The research bridges a gap in existing literature by exploring the influence of pornography on dating behavior within a culturally specific and rural context. It offers insights that extend beyond generalized findings, shedding light on how external influences interact with traditional values to impact adolescents' perceptions and behaviors. The study's findings carry direct implications for intervention strategies and policy development. By highlighting the need for culturally sensitive interventions and community-based initiatives, it offers actionable insights for fostering healthy relationship dynamics and media literacy tailored to the needs of Beringin Jaya Village. Understanding the intricate influences shaping adolescent behavior holds significance beyond academia. The study's contribution to promoting healthy relationship dynamics, informed decision-making, and respectful communication among adolescents aligns with broader societal goals of nurturing emotionally and socially healthy communities. Importantly, the research extends implications beyond the studied area. By emphasizing the importance of considering cultural contexts when examining the impact of external influences, it provides a template for understanding adolescent behavior in diverse communities, contributing to a more holistic understanding of the societal impact of external influences on adolescent development. The study's findings serve as a foundation for future research endeavors. They encourage longitudinal studies to explore the long-term impact of explicit content on adolescent behavior and advocate for community-centered approaches to mitigate potential negative effects. --- Conclusions The exploration into the influence of pornography on adolescents' dating behavior within the unique cultural tapestry of Beringin Jaya Village has unraveled critical insights that intertwine tradition, modernity, and the evolving landscape of adolescent development. This research has underscored the delicate dance between cultural values and external influences, illuminating the nuanced interplay that shapes the perceptions, attitudes, and behaviors of adolescents navigating the digital age. The findings revealed a significant prevalence of pornography exposure among adolescents, signaling an era where digital media permeates the fabric of their lives. Yet, within this landscape, emerged insights into altered perceptions of relationships, communication dynamics, and nuanced understandings of consent, often influenced by the explicit content consumed. This exploration within Beringin Jaya Village illuminated the challenges posed by external influences to the preservation of traditional values. The tension between cultural heritage and contemporary influences became evident, sparking concerns about the erosion of traditional values in the realm of relationships and intimacy. However, amidst these challenges emerged a beacon of hope in the form of tailored interventions. The findings emphasized the necessity for culturally sensitive initiatives, rooted in community engagement, media literacy, and open dialogues about healthy relationship dynamics. The significance of this research extends beyond the boundaries of Beringin Jaya Village. It serves as a guiding light for understanding the intricate interplay between cultural contexts and external influences on adolescent behavior, offering a template for fostering healthy development in diverse communities. As this study concludes, it calls for a collective effort. It beckons policymakers, educators, and communities to join hands in crafting interventions that honor tradition while embracing progress. It urges for continued research endeavors to explore the long-term impact of explicit content and advocates for communitycentered approaches as protective shields against detrimental influences. In the heart of Beringin Jaya Village lies a testament to the complexities of adolescence, a reminder that understanding and nurturing the well-being of adolescents is not merely an academic pursuit but a societal responsibility. As this research concludes, it echoes the need for a concerted effort to cultivate environments that empower adolescents, preserve cultural heritage, and foster relationships built on respect, understanding, and informed choices.

This research investigates the intricate influence of pornography on the dating behavior of adolescents within the cultural context of Beringin Jaya Village, situated in the Singing Hilir District, Kuantan Singingi Hilir Regency, Indonesia. Employing a mixed-methods approach, both quantitative and qualitative methodologies were utilized to explore the perceptions, attitudes, and behaviors of adolescents regarding pornography exposure and its impact on their dating dynamics. The study revealed a significant prevalence of pornography exposure among adolescents, correlating with altered perceptions of relationships, communication patterns, and nuanced understandings of consent. It highlighted the delicate balance between preserving traditional cultural values and navigating the challenges posed by modern influences. Findings emphasized the urgency for culturally sensitive interventions, community-based initiatives, and comprehensive sex education programs tailored to address the specific challenges posed by pornography exposure. This research serves as a beacon for understanding the complexities of adolescent development within a culturally specific context, offering insights that extend beyond Beringin Jaya Village, guiding future interventions, and fostering healthy relationship dynamics among adolescents.

Introduction Colonias are unincorporated and unregulated peri-urban settlements along the United States-Mexico border that are home to primarily Mexican-origin populations [1]. Colonia residents face unique health challenges due to poverty, lack of access to health care, inadequate infrastructure, and environmental threats. The physical health of colonia residents has been previously examined and researchers have documented significant public health challenges [2][3][4]. In spite of this, the mental health of colonia residents remains largely understudied. Westway, the site of this study of mental health, is a colonia 1 in El Paso County . In this county in 2010, 86,472 residents lived in 321 communities defined as colonias [5]. Westway is home to about 4000 of these individuals. The population is 97 % Hispanic and 45.5 % are foreign-born, and of those foreign-born residents, only 22.2 % are naturalized US citizens [6]. Westway is located next to Interstate 10, across the ArcelorMittal Vinton steel plant and proximate to other polluting industries such as a scrap metal recycling plant. In Westway, as in other colonia environments, a confluence of challenging socio-environmental conditions contributes to a difficult quality of life for residents and, as a consequence, the potential for high rates of mental health issues and barriers in coping with them. As such, we have two objectives: characterize Westway residents' rates of mental health outcomes and access to mental health care and assess intraethnic disparities in mental health outcomes within this impoverished, Hispanic population. --- Health and Environmental Concerns in Colonias Colonias tend to lack basic community infrastructure such as paved roads, sewer system, electricity, gas, clean water, and health care services [1,3,7]. The lack of infrastructure and poverty combines to foster the spread of diseases such as hepatitis, dysentery, and tuberculosis [1]. Poverty also leads to food insecurity and poor nutritional health, which can cause obesity and diabetes, which are common along the US-Mexico border [8]. Chronic illnesses, such as diabetes and asthma, are also prevalent in colonias [3]. Unsafe environmental conditions have been linked with physical illness in colonias. Underdevelopment and the presence of empty lots sometimes leads both colonia residents and others to dispose of household and industrial wastes in the neighborhoods, creating physical health risks [9]. Ramos et al. [3] found that residents living closer to junk yards or dry cleaners in the Cameron Park colonia in east Texas had significantly higher risk of developing a respiratory illness than those living farther away. In terms of mental health, the focus of this paper, Anders et al. [4] found high rates of mental illness in an El Paso County colonia ; 20 % of adults had been diagnosed with depression and 17 % had been diagnosed with anxiety. It may also be that the environmental conditions in colonias are correlated with chronic stress and psychological distress, which can permeate the physical and psychological well-being of individuals [10]. Downey and Van Willigen [11] argued that environmental stressors can have long-lasting effects on the psychological well-being of residents living in industrialized areas. While not studying colonias, Downey and Van Willigen [11] found that Illinois residents living near industrial activity reported higher depressive symptomatology, a greater sense of disorder, and more feelings of powerlessness than those not living close to industrial facilities. Similar findings relating environmental concerns to mental disorders were found in national-level datasets in Spain [12] and Portugal [13]. --- Mental Health and Access to Care for Hispanics Given that colonia residents are Mexican-origin Hispanics, it is relevant to this study that Hispanics have lower rates of mental disorders than non-Hispanic whites [14]. Within the Hispanic population, there are disparities in mental health outcomes, based on three important characteristics: nativity, language acculturation, and chronic physical illness. In terms of nativity, immigrants tend to have lower rates of mental disorders than their US-born counterparts [15,16]. Hispanics that have acculturated to white middle-class norms are more prone to develop mental health disorders. For example, Englishspeaking Hispanics have higher rates of mental disorders [17] than Hispanics who are predominantly Spanish speaking. Those suffering from chronic physical illnesses are more likely to develop a mental health condition [17]. This fact is concerning in Hispanic populations because they show an early onset and a high risk of developing conditions such as diabetes, kidney disease, and hypertension [18] which often co-occur with depression [19]. Even though Hispanics have lower rates of mental illness, the US Department of Health and Human Services has identified critical mental health disparities that apply to Hispanics, which include reduced access to mental health services, decreased likelihood to receive needed services, and poor quality treatment [20]. In terms of reduced access to needed services, foreign-born, primarily Spanish speaking, recent immigrant, first generation, and uninsured Hispanics showed the lowest rates of access to mental health services [21]. Hispanics who did not speak English received needed mental health services at lower rates than proficient English speakers [22]. Mexicanorigin people with mental health challenges have very low utilization rates for mental health services even when compared to other Hispanic subgroups, like Puerto Ricans [21]. The lack of access to quality care experienced by Hispanics makes them more prone to chronicity and higher levels of impairment due to mental illness [18]. Poor quality of care is reflected in the fact that Hispanics and other minorities' main source of mental health care is primary care physicians rather than specialists such as psychiatrists [22]. --- Other Influences on Mental Health There are other influences on mental health besides the Hispanic ethnic features and industrial concerns previously discussed. These include gender, lack of health insurance, and stressful life events. In terms of gender, women have higher rates than men of major depressive disorder, anxiety disorders, posttraumatic stress disorder, and eating disorders in the United States [23]. Lack of insurance coverage is an important barrier when in need of mental health services, and it might cause a deferment of treatment. Finally, stressful life events are associated with poor mental health because these events can "lead to stress by adversely altering the meaning of persistent life strains" [24]. --- Materials and Methods --- Study Area Westway is home to a low-income population: 49.2 % live below the poverty line, 15.4 % have an income of less than $10,000 per year, and 35 % received public assistance during the last 12 months. Only 55.4 % of Westway residents are in the labor force, mainly in service occupations, sales, construction, maintenance, and transportation [6]. Ninety-eight percent of residents are Hispanic and only 9.4 % report speaking only English at home. Over 64.3 % of Spanish speakers speak English less than very well [6]. For additional demographic information, see Table 1. Westway residents are exposed to numerous environmental hazards. Just across Interstate 10 is the steel plant, which was built in 1962 and emits zinc, lead, and manganese into the air [25]. As such, the elementary school located in Westway was ranked in the second percentile nationally in terms of bad air quality in a 2009 report [26]. Strong seasonal winds in the area provoke dust storms that spread dust from unpaved roads and lots and contaminants from industry. Residents' concerns about the environment led them to request that a team of university researchers conduct a health screening survey in their community [27]; this paper reports some of the results from that effort. --- Data Collection and Participants The first author and an assistant collected the data through door-to-door surveying between March and August 2012. Every ninth household was asked to participate. If the residents were not home, the neighbors on the left side were asked to participate. We made contact with an adult over 18 at 127 households; 23 declined and one withdrew for an 81 % response rate . For the analysis, we excluded the one non-Hispanic respondent and four relatively affluent respondents for a final N of 98 low-income respondents. The survey, translated by the first author and an assistant, both of whom are native speakers of Spanish, was offered in English and Spanish. The survey was designed by the research team through a community-based research process led by the third author. Community leaders were involved in the research process including making revisions and additions to the questionnaire. This study was approved by the Institutional Review Board at the authors' home institution. --- Measures and Analysis The first research objective involves descriptive statistics for a suite of mental health variables and access to care variables. The mental health outcomes include three sets of variables: diagnoses of specific conditions, psychological symptoms [28], and physical symptoms [29]. We utilized a physical symptomatology scale because Hispanics might tend to report physical symptoms in lieu of depression, anxiety, and/or stress [14]. Table 2 shows all variables used in the first research objective, along with information about the survey questions, coding, and descriptive statistics. The second research objective involves correlation and regression analyses. Table 3 reports descriptive statistics and details for how the independent variables were constructed. We used "industrial concerns" as our measure of environmental concern given the many industrial sources of pollution in the neighborhood and our knowledge of residents' concern about these activities in their neighborhood. Table 3 reports the same information for the four dependent variables. "Mental health diagnosis" is coded 1, if the respondent said "yes" to a diagnosis of anxiety, depression, and/or another mental health illness; it is coded 0 if the person had none of those diagnoses. "Stress and excess worry" is coded 1 if the respondent said "yes" to either or both of the questions about ever experiencing stress and ever experiencing excess worry and 0 if the person has never experienced either. "Psychological symptoms in the last 4 weeks" was created by factor analyzing six Likert items . Descriptive statistics for the Likert items contained in this factor are included in Table 3, along with the component loadings. "Physical symptoms in the last 1 week" was created by factor analyzing seven Likert items . After running bivariate correlations between the independent and dependent variables, we ran four regression models including the seven independent variables detailed in Table 3. We used binary logistic models for the dichotomous dependent variables and ordinary least squares modes for the continuous dependent variables. Collinearity diagnostics [i.e., variance inflation factors and tolerance] revealed that there were no issues with multicollinearity; all independent variables met the standard of a VIF below 2.9 and a tolerance value greater than 0.4. --- Results --- Describing Mental Health Outcomes and Access to Care One third of surveyed Hispanic residents have been diagnosed with depression and one quarter have been diagnosed with an anxiety disorder; 36 % had been diagnosed with at least one of the following mental health issues: depression, anxiety, and posttraumatic stress disorder or had attempted suicide. Nearly 60 % reported ever feeling stressed and excessively worried. In terms of access to care for mental health issues , 77 % of individuals with a diagnosed mental health condition have received health care for it. Of those receiving care for a diagnosed mental illness, 71 % receive care from their primary care physician for their diagnosed condition and 56 % take a medication. Only 7 % have seen a specialist for their diagnosis and 17 % have received a form of psychological therapy. More generally in the sample, 46 % of all respondents did not have health insurance . Of the total respondents, 18.6 % had insurance through their workplace, 20 % had Medicare, and 7 % had Medicaid. Eight percent had other forms of health insurance . Assessing Disparities in Mental Health Outcomes Table 4 presents the results from the correlational analysis between the independent and dependent variables. The following statistically significant correlations were found: Language acculturation was positively correlated with stress and excess worry. Comorbidity was positively correlated with diagnosis of mental health condition and psychological symptoms in the past 4 weeks. Being female was significantly correlated with all dependent variables. Having more stressful life events variable was positively correlated with the diagnosis variables as well as psychological and physical symptoms variables. Finally, industrial concerns were significantly correlated with stress and excess worry and psychological symptoms of distress in the past 4 weeks. Table 5 presents results from the regression models. For the logistic model predicting stress and/or excess worry , there were three significant findings and one finding that approached significance . A one-unit increase in the language acculturation scale leads to a 2.5 times increase in the odds of a respondent experiencing stress and/or excess worry. Likewise, females are 2.6 times more likely to feel stressed and/or worried than males. Individuals with one or more comorbid conditions are 2.9 times more likely to experience stress and/or excess worry. A one-unit increase in the industrial concerns scale results in a 2.5 times increase in the odds of a respondent experiencing stress and/or worry. US-born individuals are 0.8 times less likely to experience stress and/or excess worry than foreign-born individuals. For the logistic model predicting a diagnosis of a mental health condition , there were two statistically significant findings. Females and those who experienced one or more life events in the past year are both 6.9 times more likely to be diagnosed with a mental illness. For the OLS model predicting the respondent's psychological symptoms of distress in the last 4 weeks , four variables were significant at the p <0.05 level. For individuals with at least one comorbid condition, there is a 0.4 increase in the psychological symptoms scale. For females, there is an increase of 0.5 in the scale when compared to males and there is an increase of 0.7 for those who experienced one or more life events in the last year. A one-unit increase in the industrial concerns scale results in an increase of 0.255 in the psychological symptoms scale. For the OLS model predicting the respondent's physical symptoms of distress in the last week , there were three significant predictors . Females had a score on the physical symptoms scale that was 0.5 higher than males and those who experienced a life event also had an increase of 0.4 in the scale. A one-unit increase in the industrial concerns scale resulted in a 0.2 increase in the physical symptoms scale. --- Discussion In terms of rates of mental health problems, Westway residents have rates of diagnosed depression that were more than three times the rates for Texas residents and the US population in any given year [30,31]. Similarly, their anxiety rates are higher than the national rate of 18 % in any given year according to the National Institute of Mental Health [32,33]. Thirty-six percent of Westway residents report being diagnosed with at least one mental illness contrasting with the 18 % of individuals over 18 with any mental illness in Texas and the 20 % of people with any mental illness in the United States [33]. Locally, Westway residents also showed greater rates of diagnosed mental health conditions than the residents of the San Elizario colonias as previously reported by Anders et al. [4]. They found a 20 % depression rate and a 17 % anxiety rate compared to our rates of 29 and 25 %, respectively. Elevated rates of mental illness in Westway are concerning because if left untreated or undertreated, they can create unnecessary disability and further the economic challenges faced by residents [34] exacerbating inequality. Like the rest of the US population, most Westway residents diagnosed with a mental illness treat their conditions through primary care physicians. Seventy-one percent of those receiving care for depression or anxiety receive it from a primary care provider, which is slightly lower than the national statistics as 74 % of Americans who seek help for depression go to a family doctor rather than a specialist [35]. Twenty-three percent of Westway residents have not received mental health care since their diagnosis of anxiety or depression. It is probable that a lack of health insurance is related to this lack of treatment. Westway residents' most proximate source of health care services is La Fe Clinic, which is located at the north edge of the community. The clinic is part of the Centro de Salud Familiar La Fe Inc., a non-profit organization dedicated to provide health care to underserved individuals in El Paso County. Residents of El Paso County can receive a variety of services at affordable prices from this clinic, which are determined on a sliding scale according to income. The clinic also accepts Medicare or Medicaid. However, La Fe does not have mental health specialists and psychiatry is not included in their list of specialty referrals according to their website. This likely contributes to the lack of specialty care observed among surveyed residents, given that we know that a good proportion of Westway residents, especially the uninsured and those with state-sponsored insurance coverage, use the La Fe clinic for their health care needs. The lack of access to specialty mental health care is a nationwide problem. At the local level, El Paso County has only 823 mental health professionals , which is 107 for every 100,000 people [20]. In the state of Texas, only 34 % of people with mental illnesses receive needed care. The situation is worse in Westway where only 7 % of people with an anxiety or depression diagnosis have seen a specialist. Texas is the state with the least treatment dollars per capita of all states and its mental health care system has received a D grade [36,37]. The United States system also has a D grade. Nationwide, mental health care often lacks a focus on health and wellness; the data on mental health is inadequate and funding is scarce; the mental health workforce is not sufficiently maintained nor developed; and there is a deficiency in cultural competency among providers and a culture of disrespect for the mentally ill [36,37]. In terms of assessing intra-ethnic disparities in mental health outcomes, we found that Westway residents with higher levels of industrial concerns were significantly more likely to experience three of the four mental health outcomes tested here, and the fourth approached statistical significance. While not the subject of many studies (see only [12][13], the relationship between industrial concerns and mental health problems has been found in diverse social groups ranging from the population of Spain [12] to Westway, Texas. Westway residents have joined efforts with community organizations to address environmental issues in their community. They have participated with the Texas Industrial Areas Foundation in El Paso to affect policy in a number of issues including environmental health. The newer IAF group in the region, Border Interfaith , has worked with leaders in Westway to make the Texas Commission on Environmental Quality aware of their environmental concerns. After several years of pressure, TCEQ has increased their oversight, albeit on a small scale of ArcelorMittal Vinton, one of the industries near Westway [27]. Counter to the literature [14][15][16], being born in the United States is associated with having less stress and excess worry and a lower likelihood of a mental illness diagnosis and fewer psychological symptoms in the last 4 weeks among this colonia population. However, previous studies [14 -16] did not examine excess stress and worry specifically and instead focused on mental illness diagnoses. The association between being foreign-born and higher levels of stress and worry could be attributed to the fact that Westway is located near the US-Mexico border and that there are routinely law enforcement and border protection officials in the area. This police presence could cause stress and concern for foreign-born residents that are unauthorized to be in the United States [38]. Additionally, cartel violence occurring just across the border in Ciudad Juárez during the data collection may have contributed to stress and worry, especially for foreign-born residents, who likely maintained strong ties with relatives in Juárez. The strong presence of law enforcement officials and the cartel violence in Mexico as factors influencing foreign-born border residents to experience stress and worry while living in the US are hypotheses that should be investigated in future research. We found that higher scores on the language acculturation scale predicted experiencing increased stress and excess worry . This is surprising in light of the finding that foreign birth is a risk factor for stress and excess worry, although it aligns with the literature on the health-damaging effects of acculturation [17]. As expected, US-birth and language acculturation are correlated at 0.351 . It means that holding constant the effect of nativity , English speaking was associated with greater stress and excess worry. This reflects other studies finding that greater acculturation is associated with higher rates of mental illness [17]. In Westway, language acculturation approached statistical significance as a predictor of higher rates of actual diagnosed mental illness. In a study of mental health outcomes post-disaster in El Paso County, researchers also found that language acculturation was a risk factor for a mental health problem post-flood among those whose homes were damaged [39]. Comorbidity was a significant predictor of psychological symptoms in the last 4 weeks, and it approached statistical significance for the stress/worry and diagnosis variables , aligning with the strong relationship between chronic physical illness and mental disorders previously observed [18]. Given that Hispanics are at increased risk for these chronic conditions that commonly co-occur with depression, this finding is concerning from a public health perspective. Being a female was a significant predictor of the diagnosis, psychological symptoms, and physical symptoms variables, and it approached significance for stress/worry . This means that poor Hispanic women in this colonia, like women elsewhere, are more likely to experience mental health challenges [23]. Life events were also significant predictors of diagnosed mental illness, psychological symptoms, and physical symptoms of distress. --- Limitations The main limitation of this study is the small sample size , which is reflective of the small community under study . A larger sample could allow for a more sophisticated statistical analysis. Secondly, the Center for Epidemiological Studies-Depression measure [40], which is one of the most widely used instruments to measure depressive disorders, was not used in this study, limiting its comparability. Third, while beyond the scope of this community-based participatory project, we did not collect information about when the person was diagnosed with their mental illness and his/her healthcareseeking experiences. Last, studies with Hispanics of more diverse backgrounds could also provide more information on how ethnicity impacts mental health outcomes. --- Relevance Despite the numerous challenges facing individuals in colonias, their mental health has remained understudied and unaddressed by policy makers and activists. Mental illnesses can be debilitating and they further risk for physical illness complications [41] and economic decline [34]. Hispanic residents of this colonia had high rates of mental health challenges and few resources to deal with them; residents' per capita income was one quarter of the US average and half lacked health insurance. As the Hispanic population in the US continues to grow, it is becoming increasingly important to understand the complexities of Hispanic health [39,42]. This case study in a US colonia contributes to that goal by illustrating the health challenges and disparities present within this group of largely Mexican-origin, low-income Hispanics. Even within this socially marginalized group, mental health disparities were present with respect to environmental concerns, nativity, language acculturation, comorbidity, gender, and life events. These findings underscore the importance of considering intra-ethnic disparities in Hispanic health outcomes. The findings also highlight deficiencies in mental health care in the US, especially for low-income, peri-urban residents, such as those in Westway, and point to the need for increased access to mental health care at charity clinics serving poor populations. --- Conflict of Interest Guadalupe Marquez-Velarde, Sara Grineski, and Kathleen Staudt declare that they have no conflict of interest. Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000 . Informed consent was obtained from all patients for being included in the study. No animal studies were carried out by the authors for this article.

Unregulated residential settlements along the US side of the US-Mexico border, often called "colonias", are mainly populated by low-income Mexican-origin Hispanics. Colonia residents face numerous social, environmental, economic and public health challenges. Despite this, the mental health of individuals living in colonias has remained largely understudied. Drawing from a survey (N=98) conducted through a community-based participatory research project in one colonia suffering from numerous environmental and social challenges, this study analyzes residents' mental health outcomes and access to mental health care with a focus on intraethnic disparities based on environmental concerns, nativity, language acculturation, comorbidity, gender, health insurance, and stressful life events. Data were analyzed using descriptive statistics, correlation, and regression. More than one third of the residents have been diagnosed with a mental health condition and over half reported stress and excess worry. In terms of mental health care, 77 % of individuals diagnosed with a mental health problem have sought additional help mainly through a primary care provider despite the high levels of uninsured individuals. Comorbidity, being female, recent negative life events, and high levels of environmental concerns were significant predictors of negative mental health outcomes. This study contributes to the understanding of the complex health dynamics of the US Hispanic population. It also highlights the need for additional research and resources devoted to the mental health of low-income minorities in isolated communities. Keywords Mental health . Colonia . Hispanic . Environmental concerns . Mental health care . US-Mexico border 1 Officially, Westway is a collection of seven colonias (Westway 1-Westway 7; see http://www.sos.state.tx.us/border/colonias/reg-colonias/ elpaso-6.shtml), although residents treat it as one contiguous community.

Introduction Countries in the world are often grouped on socio-economic and political characteristics as belonging to the Global North or the Global South. But regardless of countries' Gross Domestic Product, people experience different degrees of privilege or suffering depending on racial, gender, and language categorizations. This article calls attention to the many brown and bilingual people from el Sur who live and study in what José Martí, the Cuban national hero, essayist, and poet, called 'las entrañas del monstruo ' . To liberate racialized bilingual Latinx students from the bowels of the English-speaking empire that often spits them out as waste, educators and scholars must take up a decolonizing sociolinguistic approach that listens to them, views them and studies them without superimposing the categories of normed languages that are named as English or Spanish or racial categories that are external to Latinx people. In so doing, we follow Audre Lorde's reminder that the master's house cannot be dismantled if we continue to use their tools. For too long, solutions to what are considered Latinx students' 'problems' have relied on tools that have NOT emerged from the Latinx experience, but on concepts external to their complex lives and language use. Here we highlight how the concept of language as a system of linguistic structures that one can 'have', as well as bilingualism as simply an addition of L1 plus L2, have been two tools of dominance that have ensured that Latinx cultural and linguistic practices remain outside of the definition of school success. This article proposes a decolonizing sociolinguistic approach that centres the complex and dynamic lives and languaging of U.S. Latinxs themselves, as we use our own tools to describe their experiences and educate them. Our tools as U.S. Latinx people can only be generated by starting with our own inside perspective, gained through our own knowledge and cultural/linguistic/semiotic systems, that is, by taking over the locus of enunciation and seizing control of the type of languaging and literacy performances that are validated in the education of Latinx students. This article builds on the work of the many Latinx community activists and scholars of colour who have made great strides in constructing a more socially just education. For example, Moll et al. focused their work on demonstrating the community's funds of knowledge, highlighting the importance of recognizing the strength of Latinx homes and communities. Guadalupe Valdés extensive scholarship has drawn attention to the languaging of the Mexican American/ Latinx communities and the 'curricularization' of language in school . Paris and Alim , building on the work of Gloria Ladson-Billings , introduced the concept of culturally sustaining pedagogy, supporting teaching that sustains linguistic and cultural pluralism. Grounded on the work of Gloria Anzaldúa on borderlands , there has been increased critical scholarship that calls attention to how Latinx youth experience life, language, and education . Dyrness and Sepúlveda and Urrieta have focused on decolonizing citizenship by showing how Latinx youth experiences transcend the nation state. In addition, a growing number of young Latinx scholars have described how Latinx children are experiencing their lives and education as transfronterizos . In many ways, the decolonizing sociolinguistic approach with which I take up the language of Latinx in this article, as well as what it means for their education, has points of contact with the work of these Latinx scholars. Despite the critical Latinx scholarship here alluded to, many uninformed educators share the view of the teacher that Sepúlveda quotes in his chapter in Dyrness and Sepúlveda : 'The problem with these [Latinx] students is that their whole world is in Spanish. They're not immersed in English' . The language of Latinos is most often identified as Spanish, a problem for educators who believe that only English has cognitive value. But often, even educators who work through Spanish, for example, bilingual teachers and teachers of Spanish as what is called a 'heritage' language, value Spanish just as something external to the ways in which Latinx students do Spanish. Latinx communities and scholars many times perceive the use of Spanish as the only educational solution. Spanish is seen as Latinx students' first language, their L1 , and the 'saviour' in our educational struggle. What is little understood is how named languages, whether English or Spanish and bilingualism as simply the addition of a second language to a first, have been often used to colonize and subjugate Latinx populations. Without denying the importance of the role that Spanish and bilingualism play in the identity of Latinx students, we consider here a different tool to view how Latinx students do language-translanguaging. I build on translanguaging's relationship to Flores and Rosa's concept of raciolinguistic ideologies to show how language and race have been co-constructed in ways that racialize Latinx students and simultaneously produce the idea that they are poor and incompetent speakers, nilingües in both English and Spanish . To denaturalize the dominance of named normed languages, whether English or Spanish, of whiteness and of maleness, we must use our own tools. Describing two Latina students taking up a Latinx locus of enunciation, that is, from an inside view and with an alternative research methodology, I will introduce Julia, a 10-year-old student who arrived in New York City from Honduras a few months ago, and Gisela, a 16-year-old who was born in New York City and whose mother was born in Mexico. 1 I then consider how the categories used by schools of language and bilingualism, external to Julia and Gisela's experiences, cast them as inferior. By closely describing their student experiences, alongside my own, I theorize the difference between perceiving their bilingualism, on the one hand, from the external perspective of dominant schooling institutions of the Global North and, on the other, from the inside perspective of bilingual speakers who have been racialized, favouring the ways of making meaning of Latinx bilinguals who live and study in the USA. --- A Latinx decolonizing research sensibility A decolonizing sociolinguistic approach does not just deconstruct concepts such as language and race, it also questions the role of research that validate categories that are external to racialized bilingual people's experiences. Research from the Global North has most often rendered the cultures and thought processes of the Global South irrelevant . Latin American decolonial scholars- Grosfoguel ; Castro-Gómez and Grosfoguel , Santos -remind us that the knowledge produced by dominant cultures are imposed as rational and scientific and given universal currency. A decolonizing approach liberates research from conceptual and methodological constraints to capture a different logic emerging from another locus of enunciation. As African sociolinguist Finex Ndhlovu has said: 'The world cannot be fully understood through the use of methods that arose out of a colonial metropolitan reading of the world' . In this article, I build on Canadian scholar Dwayne Donald's concept of 'Indigenous métissage' to adopt a Latinx decolonizing research sensibility, a way of studying people who have been colonized and racialized not simply as mestizos who use what are perceived as hybrid cultural and linguistic forms. The concept of hybridity has been used by scholars such as Homi Bhabha to discuss how discrete social practices combine in colonial settings to generate new structures, objects, and practices, which resist colonialism. But hybridity may also have the effect of essentializing a prior 'pure' state of language and cultural practices that can then stigmatize these new practices as impure and invalid. To study Latinx students with a Latinx decolonial research sensibility means to go beyond notions of hybridity and assimilation and understand their lives from their own perspective, with their own knowledge system without referencing that of the white Anglo North. Arturo Escobar has called for decolonial scholars to work within a territory of 'relationality' that does not simply take us to 'the other side', the side of whiteness, English, and dominance, but that brings all of us as a full human being into view, as we share, care, and interconnect. This requires researchers to look closely at bilingual Latinx lives and performances from within, following the Descriptive Processes proposed by Patricia Carini . Developing this research sensibility requires 'hermeneutic imagination directed towards the telling of a story that belies colonial frontier logics and fosters decolonizing' . It necessitates researchers to hold together the layered, conflictual, messy tensions of Latinx and Anglo relations and reframe those relationships informed by close looking into Latinx knowledge, cultural, and linguistic practices. Hermeneutics requires that researchers understand themselves as implicated in interpretation that fits the context and participants. Researchers thus create meaning through their interpretations, through their storytelling, rather than simply reporting findings. Following this research sensibility, I extend here the recent work of scholars questioning traditional research methodology that Bonilla-Silva and Zuberi have described as following 'white logic'. To capture translanguaging in action, some sociolinguists have called for a research methodology that captures the impromptu unplanned moments of translanguaging . For example, Li Wei has proposed Moment Analysis as an alternative research method to capture the 'lived experiences of bilingual and multilingual individuals' . He explains that this requires a 'paradigm shift, away from frequency and regularity oriented, pattern-seeking approaches to a focus on spontaneous, impromptu, and momentary actions and performances of the individual' . He further describes the methods he uses: Looking, Listening, Talking, and Thinking . Likewise, Ndhlovu relates his unplanned encounter with a 10-year-old in Johannesburg as the only way to capture O. García | 851 translanguaging, as they leverage it during their impromptu soccer game. Ndhlovu pushes us to discard traditional research methods and structures if we want to understand the spontaneous, ongoing, and negotiable practice of communication that is reflected in translanguaging. He asks: 'How realistic is it for new philosophies of language to claim they are pushing scholarship forward in a new direction when their theoretical suppositions are supported by data generated through conventional research methods?' . Here I tell the stories of two Latina students whom I came to know during my many school visits. I draw here from what I observed in some classroom 'moments'. As Li Wei explains, although some may see these descriptions as simply anecdotes, they are significant data points. Li Wei says: 'Anecdotes matter in our everyday life, and therefore should matter in discipline such as applied linguistics that deal with human beings' lived experiences' . I did not start out researching the experiences of these two students; they, and the actions that I describe, simply emerged as most significant when I look back over my 40 years of classroom close-looking. I tell the stories of these two students following a Descriptive Inquiry standpoint based on what is called the practice of Recollections, 'structured stories from life experiences' . This practice enables us to gain control of our minds and actions freeing our imagination from the shackles of knowledge systems that have been naturalized to enslave us. By describing the complexity of students' and teachers' actions, we centre their humanity . I tell the two students' stories based on my recollections of informal observations in their classrooms where significant moments emerged, as well as casual conversations that I had with them and their teacher. In telling and interpreting their stories, I make sure that there are no contradictions between the interpretation that I offer here and the experiences of the many other Latinx students whom I have encountered in classrooms over the years, as well as my own. I engage in a double narrative process, including not only the narratives of the participants but also my own voice as the narrator of those narratives, connecting the personal to the cultural. --- Decolonizing Latinx bilingualism By privileging the language doings and experiences of three Latinas-Julia, Gisela, and myself-I make visible how many traditional theories of language and bilingualism have been used to reinforce the colonial line that has divided people into, on the one hand, superior civilized human beings and, on the other hand, inferior uncivilized quasi-humans . This categorization relates to what Santos calls 'abyssal thinking' . This hegemonic thinking, made visible in the philosophy of the Martinican critical theorist Frantz Fanon , declares as nonexistent the knowledges and lifeways of those on the other side of the colonial line. I start with my own experiences as a Latina, to theorize, as Gloria Anzaldúa says, 'from the flesh', from my own 'body-politics of knowledge' . Bringing to bear thinking from an epistemological Sur , I analyze US Latinx racialized students doing their multilingualism, in concert with a southern intellectual and political trajectory of resistance to what the Peruvian decolonial theorist Aníbal Quijano ) calls coloniality, that is, the remaining effects of colonial hierarchization. Throughout this article, el Sur stands as a metaphor of human suffering produced by the hubris of epistemic superiority, whiteness, maleness, heteronormativity, named languages, and English, here enacted in the schools of the geographical north. The goal of this decolonial critique of Latinx bilingualism and their education is not simply social justice for racialized Latinx people in the USA, but epistemic and cognitive justice . This article attempts to not just unmask the political violence that is present in US schools and through which Latinx students are objectified as subjects, as some critical theories would do. Following Black feminist scholars such as Collins and Crenshaw I look at the intersectionality of linguistic, racial, sexual, political, epistemic, economic and spiritual forms of domination. As Mignolo and Walsh say, referring to decolonial thinking, 'It still means to undo, but the undoing starts from "epistemological decolonization as decoloniality"' . Cognitive justice for students from the Sur in schools from the Norte requires an ecology of knowledges ) that thinks beyond the abyssal line and that engages with what Kathleen Heugh calls transknowledging, 'the process of knowledge exchange and production' . To do so, I navigate the cracks in traditional sociolinguistic and socioeducational theories, policies, and practices that ultimately reveal their incompleteness and their role in the production of subjugated subjects. I open up established sociolinguistic and socioeducational theories, as well as traditional research methodology, to new possibilities, in effect introducing a plurality of cognitive options that include the decolonial one. --- An inside view: Julia, Gisela, and my own positionality Decolonial critiques start by unmasking oneself and operating 'con el corazón con razón en la mano' , that is, by feeling reason in the hand and body, with what Latin American decolonial theorists call a sentipensar . So, I start with positioning myself as a Latina who felt invisible when she did not speak English and yet had to struggle to perceive 'desde la tierra', from the ground, as Arturo Escobar demands for a sentipensar. The issue for me, as well as for Julia and Gisela whom we meet next, became that living in the USA engaged me in a deterritorialization of my Latin American identity, which then was quickly reterritorialized with beliefs and practices from the Anglo North that did not quite fit me , to immigration/refugee movements towards the imperialist metropolis that caused these relocations in the first place). And so, it has taken me a very long time to attempt to delink, however unsuccessfully, from the colonial matrix of power that envelops all of us as learning subjects of dominant epistemologies, and to understand that ontologies are relational, and that 'nada existe en sí, todo inter-existe', [nothing exists in and of itself, everything inter-exists] . --- Just a stupid Cuban girl My family left Cuba for New York City when I was 11 years old. I still remember the first words I understood in English when my Latina friend told the teacher: 'Don't worry about her, she's just a stupid Cuban girl'. 2 My experiences growing up were somewhat schizophrenic. On the one hand, Cubans in the 1960s received preferential treatment in the USA to that of other Latinx groups, a product of being perceived as fleeing Communism; on the other hand, I had no tierra to nurture me, for there were no diplomatic relationships between my two countries, little information, no possibility of travel. I lived in that vacuum, cognizant of not belonging neither here nor there, although fortunately sustained by a Nuyorican community that enabled me to slowly develop a Latina identity. I was fortunate to have been nurtured intellectually by many Latinx teachers in college and graduate school, and by Joshua A. Fishman, who taught me and worked with me throughout the years. The voices found in Latin American literature, coupled by sociology of language concepts, started opening my eyes to different sociolinguistic and socioeducational options. I became a bilingual teacher before there was an academic field known as bilingual education. I was privileged to have been prepared as a teacher by progressive teacher educators who focused on 'building on the strength of children'. When I started teaching in a public school in 1971, my students were 90% Puerto Ricans, but the language of instruction was English. It soon became obvious to me that their strength was their home language and cultural practices, so I started teaching 'bilingually' with texts that centred Puerto Rican experiences. I became aware that my students were doing language, as was I-speaking, performing poetry, writing narratives-using more than what textbooks determined to be English or Spanish. I was also privileged to have colleagues such as Cecelia Traugh who introduced me to Descriptive Processes and taught me to describe students closely and holistically 'from another angle'. As I started re-seeing from Latinx students' inside perspective, I began to re-see myself, questioning some of the concepts about language and bilingualism that I had been taught. My bilingual family life as wife, mother, and now grandmother, as well as my constant dialogue with a husband who is a theoretical linguist-Ricardo Otheguy-paved the way for other understandings. Yet, it was not until recently that I had the courage to give up the conceptual external lenses about language and bilingualism which had been fed to me and which proved, time and time again, ineffective in transforming the education of Latinx students. Through the work on decolonial theory and race by Latin American colleagues and some of my students and Latinx colleagues, 3 I started to look inward, from my own experiences as a Latina who grew up in a bilingual New York City community and family, and from the perspective of the many bilingual Latinx students and their teachers with whom I have worked in schools. It was then that I started to see, feel, and understand what Escobar meant by acknowledging the presence of a different world--a world that is enacted day after day by racialized Latinx bilinguals as an infinity of linguistic and cultural practices. The recollections here are based on what Li Wei calls LLTT. I looked closely, listened to the classroom interactions as well as the stories that emerged from talking to the students and their teachers, and then have been thinking and have been haunted by these stories for years. In selecting these stories to tell readers now, I have taken into consideration not only how they impacted me emotionally but also their importance for educational policies and practices. --- Julia: joy and resilience Julia is a smart, vivacious 10-year-old. She was raised by her 48-year-old grandmother in Puerto Cortés, Honduras, a port city on the north coast in her community of Black Garifunas. Julia's grandmother spoke Garifuna and Spanish to Julia from the time her mother left to work in New York when Julia was three years old. Julia's childhood seems to have been idyllic. She remembers learning how to swim when she was very young. Her grandmother had a small rowboat, and they would go out rowing together often in the laguna. With her grandmother, she also learned to fish and to be grateful for the waters and land in her life. Julia's grandmother was also a great cook, and Julia can almost taste today the fresh fish she would cook, along with plantains and red beans from her land. Julia was a precocious child. She learned how to read her grandmother's Bible when she was four, before going to school. Her mother sent remittances to send Julia to a school in town. In school, she stood out for her ability to declaim poetry. Every year there were poetry declamation contests. Julia was always among the first three galardones/awards. She also wrote poetry, often intermingling her Garifuna for poetic effects. Besides excelling in academics, Julia outshined all other students in drums, energetically producing the beat of the Punta Garifuna music she loved. In 2020 Julia's mother and grandmother made the difficult decision that it was time for Julia to reunite with her mother. The time was auspicious, given President Biden's policy of granting asylum to unaccompanied minors, and the prospect of doing the journey with the grandmother's close friend. Julia's mother paid the coyotes $3,500, and Julia left one Saturday morning accompanied by the grandmother's friend. They rode on trucks for over 2,500 miles for 10 days. When they arrived in Mexico, Julia knew what to do. She was taken along with others across the Rio Grande on an inflatable raft. She separated from her grandmother's friend and surrendered to Border Patrol agents. She used her experience declaiming poetry, and with a firm voice and histrionics, she said: 'I came alone, and I don't know anyone here. My mother lives in the Bronx and her cell phone number is xxx-xxx-xxxx'. Julia stayed in a group home for three weeks until she was able to fly to New York City to reunite with her mother. Julia arrived in the Bronx right before the Covid pandemic. She was given an English language assessment and scored low, so she was labelled an 'English language learner'. Her school did not have a bilingual education programme, so she was placed in an 'English as a New Language program' which soon was remote because of the pandemic. Her educational experience in the USA was fraught from the start. --- Gisela: a life of music and poetry Gisela is a petite 16-year-old adolescent. She has two siblings and lives in a suburb of New York City where she was born and where there is a large Mexican American community. Her mother is a nurse, and her father is a mechanic. Gisela's mother was born in Puebla, Mexico, and spoke mostly Spanish to her. Her father, also of Mexican origin, grew up in this New York suburb. Although the father mostly speaks English to Gisela, he also speaks to her in Spanish. Gisela has an older brother who usually speaks English and a younger sister who usually speaks Spanish. Gisela has many friends, and she spends a lot of time on her iPad making short videos on TikTok with her friends, and sometimes with her Mexican cousins. Her friends speak mostly English, her cousins mostly Spanish; and Gisela's videos connect in messaging, sentiment, and language to those her friends or cousins send her. In school, Gisela is considered Indigenous because she looks 'Mexican' . However, Gisela's mother has always told her, following traditions in Mexico, that she is not 'Indigenous' because she does not speak any of the Indigenous Mexican languages. When Gisela was in elementary school, she joined a Banda, a music group that plays regional Mexican music. Her mother and tíos belonged to that Banda. As she grew up, she became interested in writing and singing Latin ballads which she puts to music. Her friends in Banda and in her community want to be like Gisela, able to write and sing in ways that move some to tears and others to dance. In first grade, Gisela was given an English language assessment. She was then labelled an 'English language learner', even though she spoke English upon entering school. She was put first in an English as a second language programme, and later, in a new school, in a dual language bilingual programme where instruction was in English and Spanish. Since then, Gisela has not been 'reclassified' as a 'fluent English speaker', and is now classified as a 'Long-Term English Language Learner'. In high school, she remains in a transitional bilingual education programme that is supposed to remediate her lack of English so she could be moved to an English-only programme. --- Viewing with external tools: academic language and bilingualism In schools, Julia and Gisela are not granted the power of validating their own lives, or their linguistic and cultural practices. Instead, schools use tools that reify, rather than efface, the colonial line-academic language and additive bilingualism. --- Academic language Academic English is hailed by US scholars and educators as the panacea for academic and economic success in the USA, even though teachers cannot identify what it is, and scholars have not agreed upon a definition, despite much work . Yet, the concept has been useful to make invisible what Flores calls racialized bilingual students' own language architecture. The focus on the acquisition of this invented academic language limits the education of Julia and Gisela because it does not acknowledge them as people with talents and with presences, rather than lacks and absences. When Julia declaims her poetry, she becomes an interpreter, an actress, a singer, a musician. She uses not only her voice but also her hands and gestures, her eyes and mouth, her entire body; and sometimes she uses props, including costumes and other visual elements. She includes dance and music, as she intertwines elements of poetry drawn from what is considered the 'Spanish literary canon', with ways of expressing emotions and feelings drawn from the African rhythms of drums that accompany the Punta dance and music of Honduran origin. She draws from her entire semiotic repertoire, conveying not only the message of the poem but also the emotions and feelings it raises within her. That is, Julia links with her sentipensar, her feeling-reason in her hands and body , selecting poems that are often tied to a form of social protest over the racialization and marginalization of the Garifuna black community in Honduras. In fact, by declaiming poetry, Julia re-exists, as talented and of value. But Julia's teacher does not see her beyond her black skin and her label as an English language learner. The teacher does not know who the Garifunas are; she has never heard of Punta music; and she is not aware of the tradition of poetry declamation that exists in many schools in Latin America. The teacher does not recognize Julia's passion for the written word, and her interpretation abilities. In her English as a New Language class, the teacher is focused on teaching Julia more English academic vocabulary, ignoring the language with which she already performs. Because the teacher believes that Julia is just a learner of a language that has formal autonomous structures, she pours in vocabulary, washing away and ignoring Julia's strong language and literacy foundation. Likewise, Gisela's English Language Arts high school teacher views her as a poor English language learner and narrows her instruction to vocabulary and grammar, as she drills Gisela on the mechanics of the tasks that she will have to perform for the English graduation exam. Gisela is asked to read only abridged versions of literary texts from a book specifically designed for those labelled as Long-term English language learners which uses simple vocabulary and simplified language structures said to be 'academic'. When Gisela discusses these texts with her peers or the teacher, she is expected to do so in English only. Gisela is also supposed to write essays of the formulaic three-paragraph type, and these essays are always narrative or persuasive, and always in English only. Her ELA teacher is not aware that Gisela composes songs and writes her own lyrics, as well as music. She is not aware of Gisela's gift for using images and metaphors when she writes, or of her talent to write poetry because she only knows Gisela through the ELA curriculum for students who are expected to be poor language users. In high school, Gisela also takes a subject named Spanish for heritage speakers. Gisela is happy to be in this class, for in this class she has many other Latinx friends. But Gisela struggles with Spanish as a subject in the curriculum. The teacher is always telling Gisela and other bilinguals in the class that their language production 'está mal'. She is expected to produce her oral and written texts only in Spanish, and she is not allowed to use her full repertoire to discuss readings or prepare her written response. The teacher wants Gisela to behave as a monolingual Spanish speaker, even though all her interactions in what is considered Spanish have always been with other bilinguals. The teacher wants to make sure that Gisela acquires 'academic Spanish', restricting Gisela's languaging, and preventing her from drawing from her 'own Spanish'. Gisela's grades in the Spanish class are poor, and her bilingual languaging subsides in this classroom space. The emphasis on the acquisition of academic language, often understood simply as what racialized bilingual students 'do not have', prevents educators from engaging racialized bilinguals with a challenging education. Instead of pushing students to develop a critical consciousness with regard to their histories and lives, and nurturing their own knowledge production, it reduces education to a language programme, intent on remediating the absences that are produced when educators only acknowledge lives and practices that match those of the dominant white majority. Even when the linguistic and cultural repertoires of racialized Latinx bilingual students are acknowledged in many bilingual programmes, these simply serve as a gentle scaffold toward what is ultimately seen as the only solution--the acquisition of academic English. --- Bilingualism Another seldom understood concept in the education of racialized bilinguals is the concept of bilingualism itself. Based on understandings of language as bounded entities, and of bilingualism as two bounded languages, Latinx students are schooled in different educational programmes. 4 Despite their differences, the intent of educational programmes for Latinx students is often to eradicate their bilingualism, either rapidly in English as a second language programmes, gradually in transitional bilingual education programmes, or limiting in dual language bilingual programmes, reserving bilingual and educational privilege only for non-racialized English-speaking students. Bilingualism is important to US Latinx students, but the construct of it being either subtractive or additive leaves no room for Latinx students' dynamic bilingual practices . The strict separation of English from Spanish in the now trendy dual-language bilingual education programmes in the USA relies on the sociolinguistic concept of diglossia. This arrangement privileges the acquisition of Spanish by white monolingual students in two-way programmes. Diglossic societal arrangements in which two languages are compartmentalized have been said to have an important role in maintaining minoritized languages . However, what remains hidden is the power dimension of the hierarchical diglossic arrangement , most often related to situations of colonial oppression. In schools, these diglossic arrangements disallow any crossing of the abyssal line, thus ensuring that power remains in the hands of those who speak the dominant language and revealing how and why many of these programmes have become instruments of gentrification . The misunderstandings around the bilingualism of racialized bilinguals have led to educational practices that many times harm, rather than help Latinx students. Julia will be expected to read and write English without any so-called 'interference' from Spanish. The interference in her education, however, is being caused by a teacher who does not understand her bilingualism as being neither additive nor subtractive, but dynamic. Gisela has also been harmed by the notion that her acquisition of Spanish and of English has been incomplete , although Gisela's repertoire is full and expands in response to meaningful bilingual experiences. The beliefs in additive bilingualism and diglossia in instruction have also impacted the understandings of assessments for bilingual Latinx students. As we learned before, both Julia and Gisela were given English language assessments that expected them to make meaning of language as if they were monolinguals, not allowing them to process meaning through their own languaging but demanding that they do so through someone else's language practices. When Gisela was in fourth grade, she moved to a neighborhood that had a dual language bilingual programme, where she was also given Spanish language assessments, but no one ever looked at those scores. Even if they had been considered, they would not reveal the full picture of what Gisela knows and is able to do. Expecting Gisela to perform in only one language in assessments requires her to act as if she were two monolinguals in one, which she is not. To understand what she knows and can do and for assessments to be just and equitable, bilingual students would have to be given the same opportunity as monolingual students to use their full repertoire . The knowledge of Latinx students is sometimes held in the interstices of their bilingual and transcultural experiences. Additionally, bilingual students simply do not have practice producing language monolingually, for bilinguals are always making sense of their lives in what Gloria Anzaldúa has called an 'entre mundos', borderlands produced by the hemorrhages from their wounds/heridas, or as Mignolo and Walsh say, a lifeblood of two worlds forming a third . --- An external view of Julia and Gisela Schools view racialized students through categorizations that are external to them, molded on white middle-class monolingual English-or Spanish-speakers, or elite bilinguals, and on racial categories that negate their complexities. By perceiving Latinx students with tools external to their experiences like academic language and additive bilingualism, schools create absences. This contrasts sharply with the inside view of racialized students' experience that enables us to perceive the presence of so much that Julia and Gisela can do. As US Latinas, Julia, and Gisela are both racialized, the product of the historical colonization by Spain, political dominance by the USA, and exploitation by Latin American mostly white elites. Yet, they are differently cast in the USA. Gisela, as we have read, is perceived by teachers as 'Indigenous', 'Indian', and 'Mexican'. Despite having been born in the USA, she is often enregistered as 'illegal' or 'undocumented', as illegality has been racialized . In contrast, Julia's black skin means that she is often associated with other Afro-Americans, but rarely with being Afro-Latinx. When teachers and students first meet her, they speak to Julia in English, unsure of whether a black body can be considered Latinx or can speak Spanish. Latinx students in the USA often struggle with rigid racial classifications that do not quite fit their own sense of self. In the 2020 US census, 42% of the Latinx population identified as 'some other race', and 33% identified as having 'more than one race', resisting external rigid racial categories. In schools, the racialization of Latinx students operates through language labels such as that of 'English Language Learners' assigned to Julia and Gisela. This label casts them to the other side of the abyssal line, the side assigned to darkness, produced as unknowing, with only popular or folkloric understandings. There are several sociolinguistic assumptions made about Julia and Gisela that enables the school system to label them in this way. First, there is an assumption that English is a language entity that Julia and Gisela do not have and that they must acquire. Along with the assumption that language is a bounded entity, there is also the supposition that Julia and Gisela speak different varieties of Spanish. Second, there is a belief that Julia and Gisela have a first language, a home language, Spanish, and are learning a second language, English. Third, it is assumed that only a monolingual English or Spanish speaker can be a native speaker and that Latinx bilinguals cannot be so perceived. Fourth, given that named languages are seen as bounded entities, students can only be classified as a learner of English or fluent in English, as if these were boxes that contain all language performances. Putting these four assumptions alongside the inside view of Julia and Gisela that we have described questions these understandings. First, Julia and Gisela do language with a repertoire that includes features of what is said to be Spanish or English, and features of what is said to be Garifuna for Julia, that is, they language effectively with practices that reflect their complex lives. But the school expects them to 'have' an entity called English or Spanish with specific characteristics. A named language is a sociopolitical construction . All speakers do language, that is, they engage in languaging in ways that are inherently heterogenous, and bilinguals defy boundaries of what have been constituted as 'named languages'. Speakers also defy boundaries of what are considered 'named varieties'. In school, they say that Julia speaks Honduran Spanish, and Gisela speaks Mexican Spanish. But this only refers to some linguistic features. How different features are leveraged in the speaker's acts of communication depends on their social class, race, education, gender, identity, and purpose, as well as their contact in the US with Spanish speakers of different national origins and social characteristics. For example, Julia quickly realizes that features associated with ways of speaking of Hondurans of Garifuna background are stigmatized in the USA because of the speakers' blackness. Although Julia is fiercely proud of the ways in which she speaks Spanish, she begins to understand how racism and language are mutually constituted. US Latinx people are not only racialized by monolingual English speakers but also by other Latinx people. Second, schools assume that both Julia and Gisela are Spanish speakers learning English in school. However, we learned that Julia also speaks Garifuna, although it was not taught in her school in Honduras. And we also learned that Gisela grew up in a bilingual home. The concepts of an L1/L2 or a mother tongue do not fit their experience. It is impossible to say with certainty which language Julia and Gisela learned first and which second, for they are simultaneous bilinguals. Today, Julia feels that Spanish is the language she uses most, although she identifies more with Garifuna, and others also associate her with Garifuna. Gisela, on the other hand, recognizes English as the language she uses most and best and identifies with, although she is aware that her teachers believe that Spanish is her L1, ignoring the dynamic and socially competent ways in which she leverages her bilingualism. Third, the label English Language Learner robs someone like Gisela from performing English as a 'native speaker'. Gisela was born in the USA and has spoken English since birth. She is a native speaker of English, even though the raciolinguistic ideologies of many 'white listening subjects' look at her brown skin and hear 'broken' English . Likewise, Gisela is a native speaker of Spanish, despite the Spanish teacher demeaning it as 'Spanglish'. As Bonfiglio has said: 'The purpose of the notion of linguistic nativity, i.e. of saying that there is a certain "really native" accent, is to anchor power in a certain class of speaker' . Finally, the category of English Language Learner is opposed to that of Fluent English speaker. But as we have learned, Julia and Gisela's languaging does not take place solely with linguistic features said to be from English or Spanish. The semiotic features of their communicative repertoire include what are considered to be different multimodalities--spoken and written language, gestures, singing, dancing, and drawing--as well as features believed to belong to two different named languages. The constructed duality of English Language Learners vs. Fluent English Speakers hides the continuum of practices that make up the communicative repertoire of all bilinguals, and the fact that depending on the task, language performances can vary. By constructing only two separate student linguistic identities, bilingual students who access their full repertoire step into a non-recognized vacuum, a constructed gap that then sinks them further into a hole that produces academic failure. This is especially the case of Gisela, who has now been labelled not only as an 'English Language Learner', but as a 'Long-Term English Language Learner'. And yet, Gisela's preferred language is English, which she uses competently to do school tasks. The label English language learner is a way of marking the abyssal line that places those on the other side of the line in an existential abyss where what they know is made invisible. Julia's teacher only knows she is an English Language Learner with black skin. Her Garifuna identity and bilingualism remain hidden since she is only perceived as a Spanish speaker. Gisela's teacher only considers her as someone who has taken a 'long-term' to learn English, and thus, as a slow and disengaged student. She has neither heard of Banda; nor does she know that Gisela writes lyrics, composes songs, and is a talented singer and performer. Educating these so-called English Language Learners is then reduced to trying to move them across the abyssal line to become Fluent English speakers, not understanding that this task can never be accomplished given the colonial function of the line and the raciolinguistic ideologies that keep it in check. By casting Julia and Gisela to the other side, white monolingual students are reserved a place of privilege and can successfully be segregated to be educated for positions of power. White monolingual privilege is 'the other side' of racialized bilingual subjugation. --- Disregarding a Latinx locus of enunciation Julia and Gisela's family have moved to el Norte, but they have crossed only a geographical boundary, for they continue to be subjected to the exploitation, disregard, and extraction of resources that el Norte has produced in the geographical Sur, and to which they had also been subjected there. There are many lines of privilege/oppression, and many epistemological souths, in los Nortes and los Sures. Julia and Gisela have been raised to think of the USA as the land of possibilities. The US educational system prides itself in being 'the great equalizer'. Yet, Julia and Gisela remain mostly misunderstood and miseducated. They are neither estadounidense nor latinoamericane, and therefore, without value. In school, they are considered misfits since they do not fit the institutional language expectations. The mold of the estadounidense was cast a long time ago. It was meant to contain and give shape only to white people of Anglo-Saxon descent, said to have special virtues and a mandate from God, as enacted in the policy of Manifest Destiny, whereby the USA expanded its territory. Despite Gisela's US birth, she continues to be perceived as a brown Latina who does not speak O. García | 859 English properly and who therefore cannot be an estadounidense. Because of the continued segregation that has persisted in the USA, Gisela lives only among Latinx and African Americans. In fact, she will tell you she does not know any white people except for her teachers. Gisela rebels against a school system that refuses to value her languaging and conocimientos, her own knowledge. Anzaldúa describes conocimiento as spiritual activism, that is, the deep awareness of political and spiritual work which results in transformation of subjectivities capable of producing their own knowledge from their own locus of enunciation. An anecdote involving a moment in Julia's classroom that I observed and made note of makes evident how her locus of enunciation is disregarded in her education. One day Julia sits quietly in her ENL class where the teacher is teaching a lesson on comparative adjectives, as she emphasizes the construction 'as + adjective + as'. When Julia hears the teacher say 'as pretty', she says to herself, 'tan bonita' and immediately is transposed to Puerto Cortés, Honduras. Julia recalls 'Margarita', a poem by the Nicaraguan poet Rubén Darío which she has declaimed numerous times. She remembers the way her grandmother said when reciting the poem to her when she was little: 'Tan bonita, Margarita, tan bonita como tú'. She feels how her grandmother used to pat her cheek, as she said, 'as pretty as you'. Julia starts to really see and feel the sea in Darío's poem now turned into Puerto Cortés, where she can smell the orange blossoms in the breeze of the poem/city, and the brightness of the 'estrellas' that Margarita sets sail to cut from the sky in the poem. As she recites the poem to herself, oblivious now to the English adjectives of the lesson, she recalls the last verse of the poem: 'Guarda, niña, un gentil pensamiento/ al que un día te quiso contar un cuento'. ['Keep, my girl, a kind thought/ for the one who one day wanted to tell you a story'.] As she feels the love for her grandmother and thinks about her, she starts to cry inconsolably, while the teacher and her classmates look on surprised. When asked by the teacher, she says, 'Rubén Darío'. But the teacher has never heard of the Nicaraguan poet who initiated the Latin American literary movement of modernismo in the nineteenth century. One of her Spanishspeaking classmates translates for the teacher, 'Something about a Rubén'. No one understands the intense feelings, emotions, and conocimiento that emanate from this poem for Julia. Whereas the teaching is restricted to what the teacher knows-English and an Anglo-American canon of knowledge-Julia understands and sees new words and worlds only in relationship to her own experience. In the last verse of the 'Margarita' poem, Julia finds her sentipensar, as she enacts a 'gentil pensamiento' for her grandmother. Julia brings to the schools of El Norte a sentipensamiento that is a product of what Escobar calls a relational ontology that links what is considered rational with what is thought of as irrational and magical-feelings, intuitions, and emotions. Decolonial feminist thinker María Lugones has argued that to liberate the sentipensar, one must have an appreciation for aesthetics. In Julia's case, a poem brings forth all of her sentipensar, and yet, it remains unexpressed and unrecognized because the teacher is only concerned with the adjectives in a curriculum that is supposed to be rational and logic, casting feelings and emotions to the dark/invisible side of the line. Julia and Gisela can only learn within a pluriverso colectivo, and not a universo that only validates a unique universal truth of the real and scientific, based, of course, on the coloniality of dominance. The pluriversal, as Mignolo and Walsh have said 'connects and brings together in relation-as both pluri-and interversals-local histories, subjectivities, knowledges, narratives, and struggles against the modern/colonial order and for an otherwise' . This relational way of seeing the world require an attempt to delink from the colonial matrix of power , and to relink to a re-existence. Both Julia and Gisela live not in El Norte, and no longer in El Sur, but in an entre mundos -an in-between space, borderlands that Gloria Anzaldúa has termed with the Nahuatl word, Nepantla. Anzaldúa describes Nepantla as 'the point of contact y el lugar between worlds-between imagination and physical existence, between ordinary and nonordinary realities' . To describe and include these new subjectivities, otras formas de ver and see produced in this third space of possibility must be found, other languages beyond simply the academic English and Spanish recognized in schools, as well as other research methodologies beyond traditional ones. Decolonizing language and research: the role of translanguaging How can schools then open space for Julia and Gisela's worlds and practices, for their sentipensar, a space for the restitution of knowledge that has been dismissed, as well as border thinking? And how could language and bilingualism in school be reconstituted? Doing the work in Spanish, as some claim, is simply not enough, especially if the content is not going to include the political ontologies that result from the histories of oppression and racialization that US Latinx have experienced. And doing the work bilingually as double monolingualism is certainly not going to help either Julia or Gisela. For Latinx people living entre mundos in Nepantla, their words, worlds, and what are considered their two languages are always relational. Enacting their translanguaging , Julia and Gisela act with one unitary repertoire. Translanguaging, understood from a Latin American decolonial stance, is not simply about going across languages or even going from oral and written language across to other multimodalities. The languaging of US Latinx is NOT hybrid; it is our own, produced by a bilingual existence that will never fit the boundaries established externally of what is validated as knowledge and standardized language. Teachers who understand Latinx bilingualism as translanguaging develop pedagogical practices that bring Latinx students some measure of epistemic and cognitive justice . They leverage their knowledge, their lives, their languaging, and assess them within those parameters while extending their repertoire from the inside out. These teachers return the locus of enunciation to the Latinx bilingual community itself, as they educate . Translanguaging conceptualizes language and bilingualism not only as relational but also as political, engaged in constructing a pluriversal world in which all systems of knowledge can fit. Translanguaging denounces the coloniality of power and knowledge that has been achieved through the construction of named languages and varieties, academic language, and additive bilingualism. As Mignolo has said, 'an other tongue is the necessary condition for "an other thinking"' . For racialized bilingual students, leveraging their translanguaging becomes a process of sociopolitical engagement that enables them to produce their own transknowledging in their entre mundos. Language and bilingualism are much more than the ways in which they have been constructed in schools. To realize the potential of racialized Latinx bilinguals, one must uncover and name the intersectionalities of linguistic, racial, sexual, political, epistemic, economic, and spiritual forms of domination. To uncover and name these forms of domination requires that researchers also decolonize their own understandings of research. To exercise their sentipensar, researchers must revisit their own methodological assumptions and, as Lee has said, 'translanguage research methodologies' . A decolonial approach to the education and research of racialized bilinguals imbues with intellectual authority what has been considered spiritual, mythical, folkloric, popular, incomplete, broken, corrupted, or merely descriptive. That is, a decolonial sociolinguistic educational and research approach sheds light on the language and conocimientos that racialized bilingual students already have by opening up a space to observe and describe naturally occurring processes of languaging, teaching, and learning. It requires scholars to depict Latinx bilingual students' knowledge and linguistic practice from the inside perspective of the students themselves. It urges Latinx racialized bilingual students to produce their own conocimiento by leveraging their translanguaging and their transknowledging . --- Conclusion The work to decolonize language and education within institutions of the state is hard work. As Anzaldúa says , 'You have to plunge your hands into la masa, into embodied practical material spiritual political acts' . These acts include questioning the foundations of the knowledge systems that have been validated by research methods that "arose out of a colonial metropolitan reading of the world' . The space created by translanguaging research methodologies enables scholars to construct a new episteme of language and bilingualism that would, as the Zapatistas said, 'crear un mundo en donde quepan muchos mundos', where many worlds would fit. The language education work becomes, as Mignolo and Walsh remind us: 'a process and project in continuous insurgence, movement, and construction, a conscious action, radical activity, and praxis-based tool of affirmation, correlation and transformation' . The decolonial option to educate Latinx bilinguals entices us to detach from the overall structure of knowledge about language and bilingualism that are products of external and colonial western epistemologies and their research methodologies. Only intimate relationships with racialized bilingual lives and close descriptions of their ways of doings can reveal their strengths. An inside view shows the cracks in the knowledge system through which we have viewed and studied racialized bilingual students. This then creates the possibility of engaging in a slow epistemic reconstitution of ways of thinking and doing language and bilingualism with our own tools. This is what this article has tried to do. The openings are small, the tension and discomfort remains, and the transformation is slow, but as Latinx bilingual students, their teachers, and scholars claim their own locus of enunciation, we can tell a different Latinx story-one that opens up possibilities for a cognitively just future. --- Notes 1 Both names are pseudonyms. 2 For more on my autobiography, see García . 3 I must acknowledge here especially my Brazilian colleague, Lynn Mario Menezes de Souza, who initiated me in Latin American decolonial theory; and my many doctoral students who are too numerous to mention and who have taught me so much. 4 Most Latinx students are in schools that do not acknowledge their different histories, languaging, or cultural practices. More attention to the differing needs of Latinx students is paid when Latinx students have been classified as 'English Language Learners'. In New York, most of these emergent bilinguals are in programmes called English as a new language , in which only English is typically used. A second type of programme for Latinx emergent bilinguals are transitional bilingual education programmes. These programmes use students' bilingualism as a bridge to full acquisition of English and are based, like ESL programmes, on subtractive bilingualism assumptions that move students towards performances in English only. On the other hand, the objective of a now trendy type of bilingual education programme, dual language is supposedly that of additive bilingualism, meant to produce students who are fully bilingual and biliterate, although many times they privilege the learning of Spanish by non-Latinx students.

This article considers how the racialized bilingual Latinx students in El Norte live in an epistemological Sur where their knowledge systems, which include their language and cultural practices are discounted. Centring the schooling experience of two US Latinas today, the article theorizes the differences between perceiving their language and bilingualism from the external perspective of dominant schooling institutions of the Global North, and from the inside perspective of racialized speakers. Bringing to bear thinking from an epistemological Sur (Santos 2009), revealed through a decolonizing sociolinguistic approach and Latinx decolonizing research sensibility, the article discusses how tools external to the Latinx experience-academic language and additive bilingualism-have contributed to the subjugation and failure of Latinx students. It ends by proposing translanguaging as a tool that has emerged from Latinx own experience and how its use in their education may open a decolonial option.

Introduction In recent years, over 2,000,000 migrants and refugees have fled civil unrest and socioeconomic instability and come to Europe since 2014 in search of a better and safer future [1]. A large portion of these individuals have come from the Middle East, fleeing conflicts such as the Syrian Civil War. Migrants and refugees worldwide often encounter substantial barriers to healthcare in their new home countries [2]. The World Health Organization in the 2018 "Report on the health of refugees and migrants in the European Union" [3] indicates that there are significant limitations to the accessibility and delivery of proper healthcare, as well as to the degree of effective communication. These limitations are mainly caused by differences in language, lack of knowledge regarding available services, limited participation in the economy, the healthcare system operability in each country, and the varying cultural attitudes and beliefs. As such, migrant and refugee populations are at higher risks of poverty and social exclusion. These barriers lead to inequitable access to healthcare, which is described as a fundamental human right. To reduce and prevent health inequalities among migrants and refugees in Europe, local healthcare systems will need to adapt to the specific needs of this population. There is evidence that integration into existing healthcare systems is promoted through tailored services at the level of local communities [4]. However, little is known on how to effectively develop and run community-based healthcare models for migrants and refugees. In an effort to provide evidence-based information and practical guidance to the health professionals working at the primary healthcare level primarily in the EU Member States, the Mig-HealthCare project was launched in May 2017 [5], partially funded by the European Commission Consumer, Health, Agriculture and Food Executive Agency . The project's aim is to produce a roadmap to effective community-based healthcare models in order to improve physical and mental healthcare services, to support the inclusion and participation of migrants and refugees in European communities, and to reduce health inequalities. As part of the activities planned within this project, a systematic search in scientific databases was conducted with the objective to identify effective community-based healthcare models and interventions for migrants and refugees that could be used as best practices. We performed a comprehensive review based on a search of the international, peer-reviewed literature to identify requirements, prerequisites, and concrete steps to design and implement community-based healthcare models serving migrants and refugees. The first step was to map the different models that are reported worldwide in the academic literature, along with their characteristics, core elements, and reported outcomes. Secondly, we critically analyzed the effectiveness of the models and interventions by applying prespecified criteria. Thirdly, based on our critical analysis and criteria evaluation, a shortlist of potential best practices and tools was created. Our findings are intended to provide policy-makers and health service providers working with migrant and refugee populations the concrete steps to successfully develop strategies to address and prevent health inequalities and foster integration at the level of local communities in Europe. One of the immediate challenges of this task was the controversy surrounding the terms community-based healthcare and community health. The terms are often used in different contexts, and different countries may use the terms in different ways. Nevertheless, we believe meaningful results can be obtained from a review of publications explicitly addressing community-based models and interventions. For the purpose of this review, we use a broad conception of community as "a group of inhabitants living in a somewhat localized area under the same general regulations and having common norms, values, and organizations" [6]. Community health refers to the health status of a defined group of people and the actions and conditions, both private and public , to promote, protect, and preserve their health [7]. Migrant and refugees are terms that are often used interchangeably, but they are defined by the United Nations High Commission for Refugees as follows [8]: Migrants: "While there is no formal legal definition of an international migrant, most experts agree that an international migrant is someone who changes his or her country of usual residence, irrespective of the reason for migration or legal status. Generally, a distinction is made between short-term or temporary migration, covering movements with a duration between three and 12 months, and long-term or permanent migration, referring to a change of country of residence for a duration of one year or more". Refugees are "persons who are outside their country of origin for reasons of feared persecution, conflict, generalized violence, or other circumstances that have seriously disturbed public order and, as a result, require international protection. The refugee definition can be found in the 1951 Convention and regional refugee instruments, as well as UNHCR's Statute". --- Materials and Methods --- Search Strategy and Selection A literature search was performed for articles published in the English language following the PRISMA statement [9] in March 2018 in the databases: PubMed, EMBASE, and Scopus. Keywords and terms used were: "migrant", "immigrant", "refugee", "asylum-seeker", "healthcare", "community-based", and "model", combined with an "AND" and/or an "OR". No limits for publication dates were set; however, we divided our search in pre and post-2012 publication dates in an effort to effectively capture data on the recent migrant/refugee influx into Europe after 2011 following the civil unrest in countries of the Middle East and Africa, as our effort is of particular relevance to the present migrant/refugee crisis in Europe. Publications dated before 2012 have been published mostly with respect to migrant/refugee populations in countries outside Europe, such as the United States and Australia, in years predating the current European influx of migrants and refugees from Africa and the Middle East. --- Inclusion and Exclusion Criteria Publications were eligible for review if they provided a comprehensive description of community-based models for healthcare delivery to migrant/refugee/asylum-seeking populations or other relevant minorities, as the provision of healthcare in some of these groups depends on legal status. In our selection of relevant publications, we employed a fairly broad concept of healthcare to deliberately cover different types of healthcare services and migrant/refugee population subgroups, such as adolescents, mothers, chronic patients, and migrants. This was done in order to produce a shortlist of potential best practices and tools covering the whole range of community-based health services so as to provide a broad base of information useful to policy-makers, researchers, and funders who work in this field. Eligibility was not restricted to models and interventions for specific groups of migrants and refugees. We included all ages, ethnicities, refugees, and migrants of any status. Explicit mentioning of the terms "vulnerability" or "vulnerable" was not required for inclusion, as we considered all migrants and refugees inherently vulnerable. All publications that proposed, discussed, or formally assessed a community-based model or intervention were included in the systematic collection and analysis. We excluded publications that only reported on health needs, barriers, and challenges to healthcare access among migrants and refugees without containing the element of specific practices and tools. Papers reporting on methods for participatory community-based health research, healthcare models strictly for rural or low-resource areas, and papers on models to engage migrants in clinical research were also excluded. Abstracts and conference proceedings were excluded from the formal analysis, as an in-depth critical review was not possible to the same extent as it was for full-text publications. --- Data Extraction For all articles included in the final analysis, data was extracted on the following variables: full citation, year of publication, type of study/paper, country of implementation, target population, type of care/health needs, model/intervention , basic characteristics of the model/intervention, best practices, lessons learned, and challenges and limitations. For the critical appraisal, we also extracted data on: mode of evaluation ; duration of follow-up ; study sample ; and theoretical underpinnings . All 3054 identified articles were screened by three independent reviewers, and the results were jointly discussed. To facilitate the analysis, the publications were grouped by indication/disease area through an iterative process and, subsequently, categorized as models or interventions for health promotion/education, prevention, or disease management. --- Critical Assessment for Best Practices We define "best practices" as interventions for which there is evidence to substantiate effectiveness. To assess effectiveness, interventions described per category were evaluated based on the following criteria: study design; sample size; duration of follow-up; whether the study population was of Middle Eastern/North African descent ; reported specific outcomes/advocate evidence-based approach; presence of theoretical underpinnings; and potential for reproducibility. For each of the above-mentioned variables, a marking scheme with subcategories was applied, and the total score was calculated for each practice to assess the level of evidence for the effectiveness of interventions and models for community-based healthcare for migrants and refugees . Each study was assessed according to the criteria set in an Excel file, and the total score was computed automatically as the addition of the subscores in each category. No score threshold was set, as this was a comparative process among the interventions identified in this review. The higher the total score, the more scientifically robust the proposed intervention was indicated. 0 = not specified NA = not applicable NA = not applicable 1 = no 1 = no 1 = not mentioned NA = not applicable 1 = review/description 1 = <10 C = cross-sectional design 2 = yes 2 = yes 2 = can be reproduced 1 = not --- Results From our systematic database search, we retrieved 3054 unique records . Close screening of titles and abstracts narrowed the full text number down to 280 publications, including 22 abstracts and conference proceedings that were subsequently removed as they were not followed by any full-text publication. Based on the predefined inclusion and exclusion criteria, a total of 118 publications remained for data extraction. A full overview of the selection process is presented in Figure 1. No score threshold was set, as this was a comparative process among the interventions identified in this review. The higher the total score, the more scientifically robust the proposed intervention was indicated. --- Results From our systematic database search, we retrieved 3054 unique records . Close screening of titles and abstracts narrowed the full text number down to 280 publications, including 22 abstracts and conference proceedings that were subsequently removed as they were not followed by any full-text publication. Based on the predefined inclusion and exclusion criteria, a total of 118 publications remained for data extraction. A full overview of the selection process is presented in Figure 1. --- Overall Study Characteristics Out of 118 records, 53 discussed mental health, 36 community-based health services, 13 noncommunicable diseases , 9 primary healthcare, and 7 , maternal/women's health and child health. Countries or regions of implementation included: North America , 67/118 , Europe, 28/118 , Australia and New Zealand, 9/118 , the Middle East, 6/118 , Asia, 2/118 , and Latin America, 1/118 . Five records did not specify the area of implementation. Populations targeted included migrants, immigrants, refugees, asylum-seekers, and racial and ethnic minorities, as defined by the respective authors. All these subgroups are part of the larger definition of migrants/refugees. Some publications targeted specific population groups such as women, children, adolescents, or families; elderly patients; trauma-or torture-exposed --- Overall Study Characteristics Out of 118 records, 53 discussed mental health, 36 community-based health services, 13 noncommunicable diseases , 9 primary healthcare, and 7 , maternal/women's health and child health. Countries or regions of implementation included: North America , 67/118 , Europe, 28/118 , Australia and New Zealand, 9/118 , the Middle East, 6/118 , Asia, 2/118 , and Latin America, 1/118 . Five records did not specify the area of implementation. Populations targeted included migrants, immigrants, refugees, asylum-seekers, and racial and ethnic minorities, as defined by the respective authors. All these subgroups are part of the larger definition of migrants/refugees. Some publications targeted specific population groups such as women, children, adolescents, or families; elderly patients; trauma-or torture-exposed individuals; seasonal/farm workers; or individuals with a low income. Ethnicity or country of origin of the target population groups was mentioned in some, but not all, publications. Study designs included mostly mixed methods ; qualitative research ; surveys; and, less frequently, experimental designs . Most experimental studies were labeled as pilot studies. Community aspects were framed as either interventions implemented in the migrant community or as models or programs that rely on the engagement of different community stakeholders . The vast majority of studies were published between 2006 and 2018 . A distinction between single and complex interventions was also made. By complex interventions, we mean activities that contain a number of component parts with the potential for interactions between them that, when applied to the intended target population, produce a range of possible and variable outcomes [10]. Due to their nature, the effectiveness of complex interventions are more difficult to substantiate. some studies, further specified as of particular descent, children, tortured, newly arrived, families, and multi-ethnic adults); minorities ; immigrants ; asylum-seekers; and migrants . --- Identified Single interventions described for community-based mental health services pertained to the training of healthcare workers and cultural brokering . Training programs refer to the cross-cultural understanding and competency of healthcare workers [11,12] and the training and delivery of healthcare services among psychology or nursing students [14,15]. In terms of "cultural brokering" [12], community peers [17][18][19][20][21], bilingual gatekeepers [22], and ethnic matching of therapists and patients [13,24] were identified. Complex interventions constitute school-based programs to screen children and adolescents from migrant and refugee communities for mental health problems [16,[25][26][27][28][29], mental health promotion in community day centers [30,31], and by community organizations [32,33] and various other community-based mental health services [30][31][32][33][34][35][36][37]. Screening tools for psychosocial risk assessments were also used [20,42,43]. Core elements of the identified interventions and models were: partnering with members from target communities [44,45]; community mobilization to stimulate outreach [33,46,47]; culturally and linguistically sensitive approaches [14,45,[47][48][49][50][51][52][53]; education of health service providers on the needs of the target population [13,40,54]; awareness raising on mental health [46,55]; availability of information in relevant languages [44]; advocacy [56,57]; facilitating better integration [52]; responsiveness, coordination, and planning of different health and social services [12,54,55,58,59]; establishing a sense of belonging, community, and trust [18,58,59]; promoting empowerment and cultural competency [19,61,62]; funding [58]; and community-based participatory research [47]. --- Health Services Publications in this category are studies focusing on health promotion and access to care, mainly implemented in the USA , Europe , and Canada , and in Australia and Asia , mostly in between 2007-2018 . The populations addressed included racial and ethnic minorities; migrants ; refugees ; immigrants ; and minority children. It must be noted that the term "health services" in this review refers to all services related to health in general and not necessarily delivered within the healthcare system of which primary health care is an integral part. Single interventions that emerged constituted of: providing health information [64,65], cultural brokering through ambassadors [66][67][68][69][70][71][72], bilingual advocacy and interpretation [73,74], and a community garden project addressing a sense of community and adoption of a healthy dietary pattern [75]. Complex interventions, on the other hand, concerned community-academic partnerships [76][77][78][79][80][81], community-based nursing initiatives [82][83][84], home-based health services [83], programs on prevention, and healthcare services for the uninsured [85]. Prevalent aspects of interventions were: supervision and responsibility of stakeholders to provide equity, cultural, and linguistic competence in healthcare access and delivery [86,87]; creating a sense of community and commitment; obligation of stakeholders [68,[86][87][88]; community-based leadership that is transferring the operational supervision of the intervention to the local level to facilitate sustainability [79,89]; social networking viewed as a necessary skill along with good communication to improve the efficiency of the intervention [89,90]; and evidence-based guidelines [91,92]. Additionally, reducing discrimination [92]; the promotion of understanding of human values [84,93]; targeted outreach strategies with specific focus on health education, health promotion, disease screening, and prevention [94]; community collaboration and advocacy [74,88,91,[93][94][95][96]; raising awareness on health risks [85,86,95]; and culturally and linguistically sensitive approaches [69,71,73,74,85,87,88,91,94,97,99]. Finally, building trust between migrants and service providers [77,81,84], educating service providers on the health needs of the community [77,79,81,85,90], warranting the availability of resources [85,97] and sustainability of the programs [79,91], surveillance, and the evaluation of interventions [79,88,92]. --- Noncommunicable Diseases Studies were conducted from 2012 to 2017 in the USA , Europe , multiple countries , Canada, Australia, Middle East, and Latin America [100][101][102][103][104][105][106][107][108][109][110][111][112]. Target populations pertained to immigrants , refugees, migrants, and ethnic minorities, some of which were further defined as diabetic. Community-based strategies for the management of the following were discussed: cancer screening [100][101][102][103][104], diabetes mellitus [99,[105][106][107][108], cardiovascular disease prevention [109,110], and other chronic diseases [111,112]. Cancer-mostly breast cancer-prevention tools involved culturally tailored, narrative educational videos [100], pictograph-enhanced instructions [102], and patient-centered strategies [103,104]. The latter was also applied in diabetes mellitus management [106]. Diabetes mellitus and cardiovascular disease prevention interventions were culturally tailored approaches and story-telling [98,[103][104][105][107][108][109]. Core elements of the described practices are culturally and linguistically sensitive education [103,104,109,112], involvement and support of the migrant communities' infrastructures [110], awareness-raising about health risks [101], outreach approaches through families and community peers [101,105,111], facilitating the "community voice", intersectional collaboration, and funding [101]. --- Primary Healthcare Publications in this area of action were conducted mainly between 2012 and 2018 in Australia , the USA , Canada , and the Middle East , and populations addressed included refugees and asylum-seekers, immigrants of various descents, and vulnerable migrants [113][114][115][116][117][118][119][120][121]. Aspects of the interventions in primary healthcare discussed are engagement with the migrant community through partnerships [113,114], stronger focus on ancillary services [121], interdisciplinary collaboration between public health and primary care institutions [116][117][118], culturally and linguistically trained interpreters [118,119], evidence-based guidelines [118,119], outreach activities by nurses [120], training of staff in cultural competency [114,121], health promotion education among migrants, and advocacy [117,121]. --- Maternal, Women's and Child Health Six of the seven identified records were carried out from 2001 to 2015 in the USA , Australia , Canada, and the Middle East . Target populations involved refugees ; immigrants; racial; and ethnic minority women [122][123][124][125][126][127][128]. The main focus of interventions in this area was the reduction of maternal and child health inequalities among migrant/refugee communities, mostly through publicly funded universal health activities [122] and government-led approaches [123]. Committed community and health service provider partnerships through multiple mobilization strategies were considered successful for improving the health of pregnant women [124]. Capacity-building, as in ways to address barriers in healthcare provisions for minority populations, such as health insurance availability, healthcare cost reimbursement, healthcare advice in a native language, and culturally sensitive training of healthcare professionals, is essential; to maintain the interests of service providers and community members is essential for program sustainability. In general, partnerships between the target community and the different local healthcare providers are recommended to identify the barriers faced by women and potential solutions for improving access to care [125]. Intensive child health promotion and education campaigns using ethnic media and social networking were observed to positively affect parental awareness, knowledge, and beliefs about infectious disease prevention in children [126]. For individuals with additional health needs, such as those requiring prenatal or pediatric care, a Culturally Appropriate Resources and Education Clinic Health Advisor is recommended for specialty clinics. This type of health advisor facilitates communication, establishes a sense of community, and helps patients navigate the healthcare system [127]. To implement reproductive health services in humanitarian emergencies, facilitators are a pre-existing functioning health infrastructure, with prior training in their particular type of service delivery, dedicated leadership, and the availability of sufficient funding and resources [128]. --- Promising Best Practices at the Community Level Our assessment prioritized the 15 top best practices according to the set criteria. The top scores were 20 points , 19 points , 18 points , 17 points , 16 points , and 15 points . These 15 interventions best fit the set evaluation criteria and are presented as the most promising. In terms of the area of action, they are categorized as follows: seven in mental health, two in health service provision, two in noncommunicable diseases, two in primary healthcare, and two in maternal health . The training of health professionals, close collaborations of stakeholders, partnerships, social networks, linguistically and culturally sensitive service provisions, participatory approaches, and advocacy are elements described in these promising best practices. --- Discussion This study reviewed the academic literature for best practices in community healthcare models for migrants and refugees. We developed an evaluation tool to assess and classify the search results for their scientific robustness based on their reported characteristics, such as population size, type of intervention, achieved outcome, reproducibility, and theoretical underpinning. In the final set of identified practices, five areas of action were identified: mental health, health services, noncommunicable diseases, primary healthcare, and maternal women's and child health. All publications were thoroughly assessed per category, and then, based on the evaluation ranking , the identified interventions/best practices were prioritized in terms of scientific soundness and reproducibility potential. Partnerships between governments and community providers, the design and delivery of tailor-made educational activities for children, linguistically and culturally adapted disease prevention activities, and community and school-based interventions for mental health addressing various population groups, as well as training programs for future healthcare professionals have been shown to be efficient and reproducible ways to improve the health of vulnerable population groups such as refugees and migrants. --- Challenges-Limitations --- 1. This review is a comprehensive effort to identify community-based best practices at the primary healthcare level, addressing refugees and migrants in the peer-reviewed literature with the aim to provide information and guidance to the health professionals working at the primary healthcare level primarily in the EU Member States. This effort encountered several challenges/limitations. There is an abundance of publications regarding interventions for migrant/refugee healthcare in the peer-reviewed literature. A huge variation in the meaning of the terms community, community health or healthcare, and best practice was identified, along with an interchangeable use of the terms migrants and refugees, as well as immigrants, minorities, and asylum-seekers. --- 2. The majority of publications originated from the US, Canada, and Australia, addressing, by large, refugees and migrants at a much-progressed social integration stage compared to Europe and from very different ethnic backgrounds. --- 3. Many publications did not specify ethnicity; country of origin; or specific characteristics of the target population. 4. Despite the richness of published information, it should be noted that multiple other interventions exist that have not been published through a peer-review process, due to numerous reasons spanning from lower prioritization of the health issue to lack of resources to cover publications fees. Certainly, there can be areas of migrant/refugee health that could not be retrieved in the literature prior to March 2018, as no relevant publications were available. However, after reviewing some abstracts and conference proceedings, we have strong reasons to believe that many interventions delivered as pilot studies have not been published as full-text papers, despite the fact that they provide valuable insights into potentially effective community-based interventions. Evidently, such issues are not of lesser importance compared to the published ones. In this aspect, it is important to note that studies on migrant/refugee health issues may never materialize into a peer-reviewed publication, as they often face several barriers such as the scarcity of systematically recorded data on migrant/refugee health and a reluctance of vulnerable populations to participate in interventions stemming from communication difficulties to legal issues of residence and social exclusion, resulting in small participation rates and study samples or a difficulty in monitoring health in populations on the move, as they often change locations or even countries. The objective of the present review was to identify the best practices and tools of community-based interventions for migrants/refugees, and as such, a set of 15 practices addressing the areas of mental health, primary healthcare, health service provision, and noncommunicable disease management and prevention strategies, as well as maternal and child health, were identified based on specific evaluation criteria. The majority of projects, activities, and interventions identified in this review focus on the area of mental health, and this is an important finding that needs to be examined further, as there could be a multitude of reasons for this. The area of health service provision is also important, as well as the issue of chronic disease management, which poses as a major future challenge for healthcare systems. The primary healthcare setting is vital, as it has close links to the community and facilitates the involvement of the local population in preventing and managing diseases. It is important to note that, in almost all of the sources identified, the elements of good communication, the linguistic barriers, and the cultural elements played crucial roles in the effective applications of the interventions. Evidently, the close collaborations of the various stakeholders, the local communities, the migrant/refugee communities, and the partnerships are key elements in the successful implementation of effective primary healthcare provisions. --- Conclusions The provision of essential health services of good quality for all population groups of a society is described in the 2030 Agenda for Sustainable Development [129]. These services, as emerged from our scoping review, include health promotion, disease prevention, and disease-management activities and should aim to meet the needs of all people, especially migrants, refugees, and the vulnerable. Primary healthcare services offered at the community level can cover all aspects of health-related needs and are very effective in addressing the health needs and challenges of all. --- Author Contributions: E.R., conceptualization, methodology, publication selection and review, and evaluation criteria; S.K. , search strategy, publication selection and review, and evaluation criteria; A.C., evaluation of mental health publications; S.K. , original draft preparation; S.V., evaluation of primary healthcare and maternal and child health publications; D.L., writing-Review and editing; P.K., project administration; D.Z., appraisal of best practices; M.K., evaluation of noncommunicable diseases and of health service publications; T.P., writing-Review and editing; and A.L., funding acquisition. All authors have read and agreed to the published version of the manuscript. ---

Background: Strengthening community-based healthcare is a valuable strategy to reduce health inequalities and improve the integration of migrants and refugees into local communities in the European Union. However, little is known about how to effectively develop and run community-based healthcare models for migrants and refugees. Aiming at identifying the most-promising best practices, we performed a scoping review of the international academic literature into effective community-based healthcare models and interventions for migrants and refugees as part of the Mig-HealthCare project. Methods: A systematic search in PubMed, EMBASE, and Scopus databases was conducted in March 2018 following the PRISMA methodology. Data extraction from eligible publications included information on general study characteristics, a brief description of the intervention/model, and reported outcomes in terms of effectiveness and challenges. Subsequently, we critically assessed the available evidence per type of healthcare service according to specific criteria to establish a shortlist of the most promising best practices. Results: In total, 118 academic publications were critically reviewed and categorized in the thematic areas of mental health (n = 53), general health services (n = 36), noncommunicable diseases (n = 13), primary healthcare (n = 9), and women's maternal and child health (n = 7). Conclusion: A set of 15 of the most-promising best practices and tools in community-based healthcare for migrants and refugees were identified that include several intervention approaches per thematic category. The elements of good communication, the linguistic barriers and the cultural differences, played crucial roles in the effective application of the interventions. The close collaboration of the various stakeholders, the local communities, the migrant/refugee communities, and the partnerships is a key element in the successful implementation of primary healthcare provision.

Introduction As the cognitive component of subjective well-being , life satisfaction is defined as a person's general assessment of their living conditions [1]. The life satisfaction bottom-up theoretical approach suggests that an individual's overall life satisfaction is informed by their satisfaction in diverse life domains [2,3]. Different studies have adopted this approach to assess the influence of different life domains on overall life satisfaction at an individual level in adult samples [4][5][6][7][8]. These findings have shown that evaluations of various life domains can make independent contributions to life satisfaction [9]. The relationship between domain satisfaction and life satisfaction can be examined using the spillover model. According to this model, satisfaction in one domain positively influences other life domains as well as overall life satisfaction [10], i.e., domain satisfaction spills over into other spheres of life and on overall life satisfaction [11]. On this basis, the present study examines the contribution of three related domains-work, family and food-to overall life satisfaction. While different studies have reported positive and significant correlations between satisfaction in the job and family domains [8,12], as well as between satisfaction in the family and food domains in adult samples [13][14][15], the relationship between satisfaction in the work and food domains has not been previously assessed. However, there are studies that have demonstrated that employees with better working conditions can have family meals and cook home-made foods more frequently and have heathier diets [13,16,17]. According to the bottom-up approach, the domains that are the most immediate and important to people's lives generally exert the strongest influence on overall life satisfaction [12]. However, bottom-up studies evaluating the contribution of various life domains to overall life satisfaction have yielded mixed results, which may be due mainly to culture-related aspects and the age of the participants [4,5,12,18]. In the US, Esterling [16] concluded that financial situation, job satisfaction and family life are the main domains that explain life satisfaction, while health was a secondary sphere. In México, Rojas [19] found that the main predictors of life satisfaction were family, economic and personal satisfaction, whereas job and health seemed less relevant. Chmiel et al. [12] concluded that only satisfaction with finances and health were significant contributors to SWB in Luxemburg, while neither satisfaction with job nor family contributed to greater SWB. Loewe et al. [6] found that satisfaction with one's financial situation was the main predictor of overall life satisfaction in a sample of Chilean workers, followed by satisfaction with the family, work and health domains. Häusler et al. [5] found that satisfaction with one's financial situation, followed by satisfaction with personal relationships and job satisfaction were the most important predictors of overall life satisfaction in four European Union countries. Viñas-Bardolet et al. [8] found that satisfaction with the standard of living, followed by the domains of family, social relationships and then work, were the main contributors to life satisfaction in workers in 28 EU countries. In a United States sample, Busseri and Mise [4] found that satisfaction with close relationships , followed by satisfaction with finances, relationships with one's children and job satisfaction positively contributed to higher levels of overall life satisfaction. Regarding the relative contribution of the family and food domains to overall life satisfaction, Schnettler et al. [14] found that the contribution of satisfaction with family life was slightly higher than that of satisfaction with food-related life in undergraduate students' life satisfaction in Chile. However, when the contribution of these two domains on mothers' and adolescents' life satisfaction was assessed, the family domain was of higher importance than satisfaction in the food domain [20,21]. However, most of the available studies assessing the influence of satisfaction in life domains on overall life satisfaction have been conducted at an individual level, neglecting the interrelations between members of a couple, which is especially relevant in dual-earner couples. The Interdependence Theory [22] recognizes the importance of mutual influences , while the Family Systems Theory [23] underscores the interdependence between individuals, so that individuals involved in reciprocal relationships, such as family members, can influence one another in their thoughts, emotions and behaviors. Consistent with these theories, research has shown that life satisfaction [14,24], job satisfaction [25], satisfaction with family life [14,26] and satisfaction with food-related life [14,27] are correlated between members of a couple. Therefore, both theories make it possible to hypothesize that an individual's life satisfaction is not only influenced by their own satisfaction in different life domains but also by their partner's satisfaction in different life domains in married or cohabiting couples, which, to the best of the authors' knowledge, has not been previously assessed. In line with the Interdependence Theory and the Family Systems Theory, the "spillover-crossover" model [28] posits that experiences can be transmitted from one domain to another and to overall life satisfaction. "Spillover" is the transmission of experiences between two or more given domains; "crossover" is the transmission of experiences between domains and between individuals in close relationships [28]. Spillover involves an intra-individual transfer of experiences, while crossover is an inter-individual transmission that occurs between dyads [28,29]. The crossover process is applicable to both negative and positive experiences, with distinct dynamics [30]. Studies have reported either unidirectional crossover effects, from one partner to the other, or bidirectional effects, from one partner to the other and vice versa [31]. The bidirectional crossover requires special attention in dual-earner couples as both members of this dyad must balance work, family life and other roles, such as food-related tasks [32], and they must also fulfill different roles and tasks within their relationship [33,34]. Related to the above, another neglected issue in the study of domain satisfaction and overall life satisfaction is gender differences [35] in different-sex couples. The unilateral crossover effects are known as asymmetric, meaning that one couple member has an influence on the other, but this influence is not mutual [30]. Research shows that women are more influenced by their male partner than men are by their female partner, which may be due to women's socialization to be more sensitive to their partners [36]. Nevertheless, other studies show that men's satisfaction can also be influenced by their female partners [25,34]. In addition, when the relationship between one related variable among couples and their satisfaction with life, as well as satisfaction with different domains of life, are measured at the same time, symmetric crossover effects have been reported for some outcomes and asymmetric crossover effects for others [34,37,38]. Thus, this study contributes to the literature on satisfaction in life domains and overall life satisfaction, examining overall life satisfaction among dual-earner couples. Using couple-level data and employing dyadic data analyses, this study tests the spillover of one couple member's satisfaction in life domains on their own life satisfaction, as well as the crossover of one couple member's satisfaction in life domains to the other member's life satisfaction. Therefore, on the basis of the bottom-up approach to life satisfaction, the Interdependence Theory, the Family Systems Theory and the SCM, the aims of the present study were a) to explore the spillover and crossover associations between job satisfaction, satisfaction with family life, satisfaction with food-related life and overall life satisfaction in dual-earner couples with adolescent children, and b) to explore differences between spillover and crossover effects according to the gender of the couple members. Families with adolescent children were considered for this study as adolescence has been found to be particularly challenging for parental well-being [39]. Job satisfaction is traditionally defined by how employees feel and think about their work [11], which includes measuring individuals' emotional states, affective responses and cognitive evaluations of work [40]. Different authors have suggested that the job domain determines the level of life satisfaction, given that work is one of the most important parts of an individual's life and takes a large share of their time [41,42]. However, Edralin [43] stressed that this relationship can result in positive and negative outcomes, which in turn may lead to elevated satisfaction levels in some individuals and stress in others. In this regard, there is evidence showing a negative relationship between the job domain and overall life satisfaction [44] and even showing a lack of relationship between them [45]. Nevertheless, consistent with the positive outcome highlighted by Edralin [43], several studies support a positive relationship between job satisfaction and overall life satisfaction at an individual level in workers in different countries [5,6,11,41,42,46,47]. Research based on the SCM has mostly investigated the crossover of negative experiences involving the work and health domains [30], but there is evidence in the SCM literature which leads to the expectation of crossover effects between job satisfaction and life satisfaction among members of dual-earner couples. For instance, in dual-earner couples, Sanz-Vergel and Rodríguez-Muñoz [48] found that the individual's work enjoyment was positively related to their own daily well-being ; this, in turn, was transmitted to the partner . In addition, there is also evidence showing at least unidirectional crossover associations between work-related variables and life satisfaction in dual earner-couples. Liu and Cheung [25] found that work-to-family enrichment in women was positively associated with their husbands' life satisfaction but not vice versa. Schnettler et al. [38] found that in men, work-life balance was positively associated with their own satisfaction with life as well as with their female partner's life satisfaction; in women, however, their work-life balance was positively associated with their own satisfaction with life, but not with that of their male partner. Therefore, we pose the following hypotheses: H1: A man's job satisfaction is positively associated with his life satisfaction . H2: A man's job satisfaction is positively associated with his partner's life satisfaction . H3: A woman's job satisfaction is positively associated with her life satisfaction . H4: A woman's job satisfaction is positively associated with her partner's life satisfaction . Family forms a key unit of society which plays a crucial role in the individual's psychological and social development [49,50]. The relevant role of the family domain for well-being has been stressed by numerous studies in adult samples [4,6,7,51]. Part of this role can be assessed using the concept of family life satisfaction, the person's assessment of their own family life based on their own subjective criteria [52]. It has been reported that having good relationships within the family and greater levels of attachment are beneficial for a family member's life satisfaction [53]. In this regard, different studies using the life satisfaction bottom-up approach have supported a positive relationship between satisfaction with family life and overall life satisfaction at an individual level in different countries [6,8,18,21,41,47,54]. Although positive crossover from the family domain to overall life satisfaction is an under-studied field, there is evidence that at least unidirectional crossover effects between satisfaction with family life and life satisfaction in dual-earner couples can be expected. On the basis of the SCM, Chen [55] found that in Taiwan, fathers' involvement in parenting tasks positively influences their own and the mothers' life satisfaction, while mothers' involvement in parenting tasks influences their own life satisfaction but not the fathers'. In addition, Schnettler et al. [56], using multivariate ordinal logit models, found that mothers' life satisfaction was positively influenced by their own satisfaction with family life as well as by the fathers' satisfaction with family life and vice versa, in a Chilean sample of dual-headed households. Therefore, we pose the following hypotheses: H5: A man's satisfaction with family life is positively associated with his life satisfaction . H6: A man's satisfaction with family life is positively associated with his partner's life satisfaction . H7: A woman's satisfaction with family life is positively associated with her life satisfaction . H8: A woman's satisfaction with family life is positively associated with her partner's life satisfaction . The food domain has been relatively less studied in the literature of domain satisfaction, despite the fundamental role that food-related issues play in people's short-term and long-term well-being [57]. An important part of an average person's life is dedicated to investing time, energy and financial resources on food and food consumption [38,57,58]. In addition, food not only provides nourishment and sustenance but also carries cultural and symbolic meaning [59]; thus, for individuals and groups, the social value of food entails more than nutrition [38,60,61]. A person's overall cognitive assessment of their food and eating habits is defined as satisfaction with food-related life [58]. Satisfaction with food-related life and life satisfaction have been shown to be related in adults from different countries [62][63][64][65]. In addition, some studies based on the bottom-up approach to life satisfaction have also supported a positive relationship between satisfaction with food-related life and overall life satisfaction at an individual level in adult samples [15,21,66,67]. For crossover effects in the food domain, there is only one published study that assessed spillover and crossover effects between family members regarding satisfaction with food-related life and life satisfaction [38]. However, the evidence provided by these authors shows that at least unidirectional crossover effects between satisfaction with food-related life and life satisfaction among members of dual-earner couples is to be expected. Although no crossover effects were detected between the two parents and one adolescent child, fathers' satisfaction with food-related life was positively associated with their own life satisfaction as well as with their partners' satisfaction with life, while the mothers' satisfaction with food-related life was positively associated with their own life satisfaction but not with their male partners' [38]. Therefore, we pose the following hypotheses: H9: A man's satisfaction with food-related life is positively associated with his life satisfaction . H10: A man's satisfaction with food-related life is positively associated with his partner's life satisfaction . H11: A woman's satisfaction with food-related life is positively associated with her life satisfaction . H12: A woman's satisfaction with food-related life is positively associated with her partner's life satisfaction . Another important issue scarcely explored in the relationship between satisfaction in life domains and overall life satisfaction is gender differences. According to Jovanović et al. [35], the association between satisfaction in life domains and overall life satisfaction may differ between men and women, as both groups manifest different socialization practices and play different social roles. However, although it is feasible that men and women derive overall life satisfaction from different domains and sources, the scarce evidence is mixed. Diner and Fujita [68] found that social resources are more strongly related to life satisfaction in women than men. Pinquart and Sorensen [69] reported that income has been more strongly associated with life satisfaction in men than in women. However, a later study concluded that the importance of social resources for overall life satisfaction did not differ between women and men in some countries [35]. In addition to the differences in women's socialization [36], Westman [70] suggested that gender differences may be related to the distinct ways men and women react to what happens to their partner, their degree of involvement in family affairs and in traditional gender-based demands and expectations. Namely, women tend to be more involved in family activities and seem to be more responsive to situations affecting their male partners than men [26]. In summary, while some studies have found gender differences in spillover and crossover effects in couples [37,71], others report the opposite [26,72] or mixed results [73]. Two considerations are made here to begin to make sense of these inconsistent findings. First, gender role theory posits that family roles are more relevant to women's identities, while work roles are more relevant to men's identities [74]. The second consideration is that this study is conducted in a Latin American country, in which a traditional family structure still prevails; that is, men are positioned as the main breadwinners and women remain responsible for running the household and overseeing family issues, even if they work outside the home [56]. On this two-fold basis, we pose the following hypotheses: H13: The spillover relationship between men's job satisfaction and their own life satisfaction is significantly higher than the crossover association between their partners' job satisfaction and the men's life satisfaction. --- H14: The spillover relationship between women's job satisfaction and their own life satisfaction is significantly lower than the crossover association between their partners' job satisfaction and the women's life satisfaction. --- H15: The spillover relationship between men's satisfaction with family life and their own life satisfaction is significantly lower than the crossover association between their partners' satisfaction with family life and the men's life satisfaction. --- H16: The spillover relationship between women's satisfaction with family life and their own life satisfaction is significantly higher than the crossover association between their partners' satisfaction with family life and the women's life satisfaction. --- H17: The spillover relationship between men's satisfaction with food-related life and their own life satisfaction is significantly lower than the crossover association between their partner's satisfaction with food-related life and the men's life satisfaction. --- H18: The spillover relationship between women's satisfaction with food-related life and their own life satisfaction is significantly higher than the crossover association between their partners' satisfaction with food-related life and the women's life satisfaction. --- Materials and Methods --- Sample and Procedure Using non-probability sampling, 473 different-sex dual-earner couples were recruited in Temuco, Chile . Inclusion criteria were the couple had at least one adolescent child between 10 and 15 years of age and both mother and father had a paid job. Participants were recruited from seven schools which represented varied socioeconomical status. Trained interviewers contacted parents and provided information about the study's objectives, the strict anonymity and confidentiality of the responses and the structure of the questionnaire. Those couples in which both members agreed to participate were visited in their homes by the interviewers between August and December 2020. After the parents signed the informed consent form, interviewers personally administered the questionnaires separately to each parent, recording their responses in a QuestionPro questionnaire. After responding to both questionnaires, each couple received a gift card worth approximately USD 15. The Ethics Committee of the Universidad de La Frontera approved the study protocol . A pilot test was conducted for the surveys with 20 families, following the same recruitment method. The pilot test was deemed satisfactory; thus, no changes were made to the questionnaires or the interview procedure. --- Measures Satisfaction with Life Scale : The SWLS [1] is a five-item scale with a single dimension to evaluate the participant's overall cognitive judgments about their life . Respondents indicate their degree of agreement with each statement using a 6-point Likert scale . The Spanish version of the SWLS was used [75]. SWLS scores are obtained from the sum of the scores from the five items. Overall Job Satisfaction Scale . Job satisfaction was measured using the six items selected by Agho, Price and Mueller [76] from the original 18-item index developed by Brayfield and Rothe [77]. The OJSS has previously shown good internal consistency in different countries [78][79][80]. Respondents indicated their degree of agreement with each statement using a 5-point Likert scale . The Spanish version of the OJSS scale was used [81]. OJSS scores are obtained from the sum of the scores from the six items. Satisfaction with Family Life : Family life satisfaction is the "conscious cognitive judgment of one's family life based on the subjective criteria of each individual" [52]. Zabriskie and McCormick [52] proposed this adaptation of the SWLS [1], replacing the word "life" in the five original items with "family life". Respondents indicate their degree of agreement with each of the statements using a 6-point Likert scale . The Spanish version of the SWFaL was used [15]. Satisfaction with Food-related Life : The SWFoL [58] is a five-item scale that evaluates a person's overall assessment of their food and eating habits . Respondents indicate their degree of agreement with each statement using a 6-point Likert scale . The Spanish version of the SWFoL was used [75]. SWFoL scores were obtained via from the sum of the scores from the five items. The Spanish-language versions of the OJSS, SWLS, SWFoL and SWFaL have previously shown good internal consistency with adult samples in Chile [14,15,20,21,34]. Both members of the couple were asked about their age, type of employment and number of working hours per week. Women reported the number of family members, the number of children, the gender of the person with the highest income in the couple and the number of days that both members of the couple eat together during the week. The socioeconomic status was determined based on the total household income and its size [81]. --- Data Analysis Descriptive analyses were conducted using SPSS v.23. Following Claxton, DeLuca and van Dulmen [82], a dyadic confirmatory factor analysis was used to examine each scale used in this study in terms of their latent structure and their psychometric properties. Internal consistency was tested using the Omega coefficient [83]. Convergent validity was assessed by inspecting the standardized factor loadings of each scale as well as their significance and average variance extracted [83]. Discriminant validity was supported by comparing the AVE for each scale with the square of the correlation between the factorial scores of the scales [84]. To test the hypotheses, structural equation modeling [85] was used to assess the actor-partner interdependence model with distinguishable dyads. The unit of analysis for the APIM is the dyad and the interaction between its members; each member is an actor and a partner in this analysis [85]. Therefore, it was proposed that the job satisfaction, satisfaction with family life and satisfaction with food-related life of each partner was potentially associated with both partners' life satisfaction. "Actor effects", or spillover, are those relationships between the job satisfaction, satisfaction with family life and satisfaction with food-related life of one member of the dyad with their own life satisfaction. "Partner effects", or crossover, are the relationships between the levels of job satisfaction, satisfaction with family life and satisfaction with food-related life of one member of the dyad with the life satisfaction of the other member of the dyad. The APIM controls for the level of influence of one partner's satisfaction on the other by correlating the independent variables of each dyad member . The APIM also allows to examine correlations between the residual errors of the dependent variables of each dyad member , thus controlling for other sources of interdependence between partners [85]. The basic model for spillover-crossover between domain satisfaction and overall life satisfaction is shown in Figure 1. Am: Actor effect of a man's domain satisfactions on his own life satisfaction; Af: actor effect of a woman's domain satisfactions on her own life satisfaction; Pfm: partner effect of men's domain satisfactions on women's life satisfaction; Pmf: partner effect of women's domain satisfactions on men's life satisfaction; Em and Ef: residual errors on life satisfaction for men and women, respectively. In modeling the fit of the data, the effects of number of children and family SES were controlled for by incorporating those variables with a direct effect on the dependent variable. The CFA and SEM were conducted using MPlus 7.11. The parameters of the CFA and structural models were estimated via robust unweighted least squares . Both analyses were performed using a polychoric correlation matrix, which considered the ordinal scale of the items. The Tucker-Lewis index and the comparative fit index were used to determine the model fit of the data. The value of 0.90 was considered a cut-off point for establishing an acceptable fit; both the TLI and the CFI had a value above 0.95, which indicated a good fit. In addition, the root mean square error of approximation was considered as a poorness-of-fit measurement. A RMSEA value lower than 0.06 indicates a good fit, while a value lower than 0.08 indicates an acceptable fit [86][87][88]. As a last step, differences between spillover and crossover effects were explored based on the gender of the couple members. Differences between both path coefficients were tested using a structural equation model. A m : Actor effect of a man's domain satisfactions on his own life satisfaction; A f : actor effect of a woman's domain satisfactions on her own life satisfaction; P fm : partner effect of men's domain satisfactions on women's life satisfaction; P mf : partner effect of women's domain satisfactions on men's life satisfaction; E m and E f : residual errors on life satisfaction for men and women, respectively. --- Results In modeling the fit of the data, the effects of number of children and family SES were controlled for by incorporating those variables with a direct effect on the dependent variable. The CFA and SEM were conducted using MPlus 7.11. The parameters of the CFA and structural models were estimated via robust unweighted least squares . Both analyses were performed using a polychoric correlation matrix, which considered the ordinal scale of the items. The Tucker-Lewis index and the comparative fit index were used to determine the model fit of the data. The value of 0.90 was considered a cut-off point for establishing an acceptable fit; both the TLI and the CFI had a value above 0.95, which indicated a good fit. In addition, the root mean square error of approximation was considered as a poorness-of-fit measurement. A RMSEA value lower than 0.06 indicates a good fit, while a value lower than 0.08 indicates an acceptable fit [86][87][88]. As a last step, differences between spillover and crossover effects were explored based on the gender of the couple members. Differences between both path coefficients were tested using a structural equation model. --- Results --- Sample Description The sociodemographic characteristics of the sample are displayed in Table 1. This table also shows their average OJJS, SWLS, SWFoL and SWFaL scores. The mean age for women was 39.1; for men it was 42.0 years. The couples reported four family members and two children on average. Most couples corresponded to middle SES and reported that the man was the earner of the highest income. The average days per week in which both members of the couple ate together were low for the three mealtimes asked. Most women and men worked as an employee and had a 45-h work week . Regarding differences between couple members, men were older than women . Men had a higher average score than the women on the SWLS , SWFaL and SWFoL scales . Men were the greater proportion of workers with a 45-h work week . Women and men had similar average scores on the OJJS and similar proportions of employees and self-employed workers . --- Psychometric Properties of the Scales Results for the dyadic CFAs indicated that the measurement models of OJJS , SWFaL , SWFoL and SWLS have good or at least acceptable fit to the data for both members of the couple. All scales showed good reliability with Omega coefficients between 0.89 and 0.99 and AVE values above 0.50. The size of factor loadings supports convergent validity, as all were statistically significant and had values above 0.5. All AVE values are greater than the square correlation between the factorial scores of the scales, which supports discriminant validity . Regarding the correlations between the factorial scores of the scales, the three domains correlated positively and significantly in men and women. According to Cohen [87], the correlations between job satisfaction and satisfaction with family life and between job satisfaction and satisfaction with food-related life were of low strength, while the correlations between satisfaction with family life and satisfaction with food-related life were of medium strength in both members of the couple . --- APIM Results The effects of number of children and family SES were controlled for in the model that assessed the APIM. This model's associations between both couple members' job satisfaction, satisfaction with family life and satisfaction with food-related life, and their levels of life satisfaction, had fit indices that showed a good fit with the data . As shown in Figure 2, significant correlations were found for both members of the couple for job satisfaction , satisfaction with family life and satisfaction with food-related life . The correlation between the residual errors of each member of the couple's life satisfaction was not significant . correlated positively and significantly in men and women. According to Cohen [87], the correlations between job satisfaction and satisfaction with family life and between job satisfaction and satisfaction with food-related life were of low strength, while the correlations between satisfaction with family life and satisfaction with food-related life were of medium strength in both members of the couple . --- APIM Results The effects of number of children and family SES were controlled for in the model that assessed the APIM. This model's associations between both couple members' job satisfaction, satisfaction with family life and satisfaction with food-related life, and their levels of life satisfaction, had fit indices that showed a good fit with the data . As shown in Figure 2, significant correlations were found for both members of the couple for job satisfaction , satisfaction with family life and satisfaction with food-related life . The correlation between the residual errors of each member of the couple's life satisfaction was not significant . Figure 2 displays the results from the estimation of the structural model. Regarding job satisfaction results, the path coefficients indicated that a man's job satisfaction was positively associated with his own life satisfaction , thus supporting H1. The path coefficients also indicated that a man's job satisfaction was positively associated with his female partner's life satisfaction , supporting H2. Likewise, the path coefficients indicated that the woman's job satisfaction was positively associated with her own life satisfaction , which supports H3. Path coefficients also indicated that woman's job satisfaction was not significantly associated with her male partner's life satisfaction , and thus H4 was not supported. The path coefficients for satisfaction with family life indicated that a man's satisfaction with family life was positively associated with his own life satisfaction , thus supporting H5, and that a man's satisfaction with family life was positively associated with his female partner's life satisfaction , thus supporting H6. Likewise, the path coefficients indicated that a woman's satisfaction with family life was positively associated with her own life satisfaction , thus supporting H7, and that the woman's satisfaction with family life was significantly associated with her male partner's life satisfaction , thus supporting H8. The path coefficient for satisfaction with food-related life indicated that a man's satisfaction with food-related life was positively associated with his own life satisfaction , thus supporting H9. Path coefficients indicated that a man's satisfaction with food-related life was not significantly associated with his female partner's life satisfaction , hence H10 was not supported. Likewise, the path coefficient indicated that a woman's satisfaction with food-related life was positively associated with her own level of life satisfaction , thus supporting H11. Path coefficients indicated that a woman's satisfaction with food-related life was not significantly associated with her male partner's life satisfaction , thus not supporting H12. The control variables did not significantly affect the model. The path coefficients for the number of children and SES on the man's life satisfaction were 0.022 and -0.059 , respectively. The path coefficients for the number of children and SES on the woman's life satisfaction were 0.062 and -0.035 , respectively. --- Testing Gender Differences Results from the analysis by gender showed that the association of a man's job satisfaction and his own life satisfaction was significantly higher than the association of a woman's job satisfaction and the man's life satisfaction , thus supporting H13. By contrast, the association of a woman's job satisfaction and her own life satisfaction did not differ from the association of a man's job satisfaction and the woman's life satisfaction , thus not supporting H14. Next, the association between satisfaction with family life and life satisfaction was tested. It was found that a man's satisfaction with family life and his own life satisfaction was significantly higher than the association of a woman's satisfaction with family life and the man's life satisfaction , thus not supporting H15. The association of a woman's satisfaction with family life and her own life satisfaction was significantly higher than the association of a man's satisfaction with family life and the woman's life satisfaction , thus supporting H16. Lastly, the association of a man's satisfaction with food-related life and his own life satisfaction did not differ from the association of a woman's satisfaction with food-related life and the man's life satisfaction , thus not supporting H17. The association of a woman's satisfaction with food-related life and her own life satisfaction was significantly higher than the association of a man's satisfaction with food-related life and the woman's life satisfaction , thus supporting H18. In summary, as it was hypothesized, for men, spillover associations between job satisfaction and life satisfaction were significantly higher than crossover associations from women's job satisfaction. Likewise, for women, spillover associations between satisfaction with family life and life satisfaction, as well as between satisfaction with food-related life and life satisfaction, were significantly higher than crossover associations from men's family and food-related life satisfaction . On the other hand, contrary to what was hypothesized, for men, the spillover association between satisfaction with family life and life satisfaction was significantly higher than the crossover association from women's satisfaction with family life. For women, no statistical differences were found between spillover and crossover associations between their own and the men's job satisfaction and their life satisfaction. Similarly, for men, no statistical differences were found between spillover and crossover associations between their own and the women's satisfaction with food-related life and their own life satisfaction. --- Discussion Using the APIM approach, this is the first study that explores the spillover and crossover associations between job satisfaction, satisfaction with family life, satisfaction with food-related life and overall life satisfaction in dual-earner couples. As hypothesized, consistent with the bottom-up theoretical approach to life satisfaction [2,3], our results show positive relationships between job satisfaction and life satisfaction in both members of the couple, which confirms previous studies conducted at an individual level in different countries [5,6,11,41,42,46,47,89]. Similarly, the positive spillover between satisfaction with family life and overall life satisfaction in both members of the dyad is consistent with previous studies conducted on the basis of the life satisfaction bottom-up approach, which concluded that the family domain is a significant contributor for life satisfaction at an individual level also in different countries [6,8,18,21,41,47,54]. Likewise, the findings supported a positive spillover between satisfaction with food-related life and overall life satisfaction in both members of the couple, in line with previous research examining the bottom-up approach to life satisfaction at an individual level [15,21,64,67]. Taking into account the contribution of the three domains to overall life satisfaction, the high strength correlation between satisfaction with family life and overall life satisfaction in both members of the couple is consistent with previous studies concluding that satisfaction in the family domain is a stronger contributor to overall life satisfaction than satisfaction in the job [8,19,42] and food [20,21] domains. The strong association between satisfaction with family life and overall life satisfaction is also in line with studies reporting that satisfaction with close relationships, such as a spouse, and relationships with one's children made a greater contribution to overall life satisfaction than satisfaction in the job domain [4]. Nevertheless, it is worth noting that satisfaction with family life was the main contributor to life satisfaction for both members of the couple. This finding is in line with the results reported by Jovanović et al. [35] with a sample of undergraduate students in Iran regarding the lack of differences among women and men in the importance of social resources for overall life satisfaction. However, this result contradicts research conducted with undergraduate students in the US and Croatia indicating that social resources are more strongly associated with women's life satisfaction than with men's [35,68]. Thus, our results confirm that the importance of social resources, such as family life, for overall life satisfaction is age-and culture-sensitive [4,5,12], showing that the family domain is relevant for men and women in dual-earner couples in the stage of life under study , although the literature indicates that women get more involved in the family domain [26,74]. Regarding the relative importance of the two other domains as contributors to life satisfaction for women and men, the results support the suggestion that their different socialization practices and social roles may lead men and women to derive overall life satisfaction from different domains [35]. This can be seen in the results, as the spillover association between satisfaction with food-related life and life satisfaction was stronger than the association between job satisfaction and life satisfaction in women, while the opposite trend was found in men. As in other countries, in Chilean dual-headed households, women are still primarily responsible for feeding the family [56], while men are still considered the main provider [90]. In addition to gender roles and differences in socialization, there are other possible explanations related to the positive association between life satisfaction, satisfaction with food-related life and healthy diets [15,62,64,65,67]. The higher relevance of satisfaction in the food domain for women than for men may be related to the evidence showing that women have healthier diets than men [15,91], because women are more invested in engaging in healthful diets for their own and also for their families than men [38,56,92]. In addition, it has been found that male employees report more obstacles to achieving a high level of satisfaction with food-related life than women, such as lacking a fixed mealtime schedule and having insufficient time to eat at the workplace [37]. Between members of the couple, the following crossover effects were found: one symmetric or bidirectional positive crossover between satisfaction with family life and life satisfaction ; one unidirectional or asymmetric positive crossover between job satisfaction and overall life satisfaction . There were no crossovers between satisfaction with food-related life and overall life satisfaction. The findings regarding satisfaction with family life and job satisfaction are consistent with the suggestion by Liu and Cheung [25] that male partners may differ from their female partners in the significance or strength of the hypothesized crossover relationships, according to the type of outcome variables under consideration. Fredrickson's "broaden and build theory" [93] may shed light on the underlying mechanisms through which one partner's satisfaction with family life or job satisfaction affects the other partner's life satisfaction. This theory suggests that positive emotions linked to an individual's satisfaction in a determined domain promote externally oriented thoughts and actions; these responses further stimulate the person to respond positively to the needs of their partner by showing sympathy or concern about family or job issues, as in the present study. Accordingly, the partner perceives an improvement in the relationship, which in turn enhances their subjective well-being [25]. Consistent with the SCM [28], previous empirical findings [56] and authors who have reported symmetrical crossover associations among couples [31], our results show a significant correlation between one partner's satisfaction with family life and the other partner's life satisfaction, and vice versa. Namely, women's satisfaction with family life crosses over to men's life satisfaction, and men's satisfaction with family life crosses over to women's life satisfaction. These results are also in line with the Interdependence Theory [22] and the Family Systems Theory [23] regarding the interdependence between couples and members of a family. Although the spillover associations in each member of the couple were stronger than the crossover associations, these results show that an individual's life satisfaction would not only be influenced by their own satisfaction with family life but also by their partner's satisfaction with family life in dual-earner couples. The positive crossover between satisfaction with family life and overall life satisfaction between the couple members may be explained by the interrelations between both partners, who share significant aspects of their lives, especially in the family domain [30,32]. Therefore, in this context, it is likely that direct crossovers occur among members of a couple, meaning that partners transmit or exchange experiences, affective states and resources through empathy [94]. According to the mechanism of direct crossover, it can be suggested that satisfaction with family life in men produces an empathetic reaction in women that increases their life satisfaction, and vice versa [62]. However, it is worth highlighting that crossover was bidirectional. This finding may be related to an increase in positive interactions between partners when both are satisfied with their family life, which in turn increases their well-being [30]. However, further research is needed in more individualistic cultural contexts given the high importance of family in Latin American culture [95]. There was a unidirectional crossover from a man's job satisfaction to his partner's life satisfaction, whereas his life satisfaction was not associated with his partners' job satisfaction. Following Westman [70], our findings show that a direct crossover occurs but only through women's empathy, i.e., only men's job satisfaction produces an empathetic reaction in women, which in turn increases their life satisfaction, but not vice versa. This result may be linked to a more traditional socialization of women [36], who are encouraged more than men to be attuned to the feelings and emotions of other people. In parallel, our findings are consistent with previous studies reporting that men tend to be less sensitive to their female partners' positive experiences in the job domain, such as a female partner's greater work-to-family enrichment and work-life balance [25,37]. These findings may also reflect traditional gender-based demands and expectations [70]. Given the traditional role of men as the family's main "breadwinner" [74], as occurs in most of the sample under study, it is likely that the family's financial situation depends more on the man's than the woman's job. Therefore, considering the importance of the financial situation to an individual's life satisfaction [4][5][6]12,18,19], it is feasible that the greater importance of the man's job for the family's total income influence not only relates to their own overall life satisfaction but also to their partner's. Contrary to what was expected [38], no crossover associations between satisfaction with food-related life and overall life satisfaction were found between partners. Other dyadic studies have reported a similar lack of crossover effects [30], yet this is an unexpected result in this study, as previous evidence suggests that individuals who share the same environment and experiences also share eating habits and satisfaction with food-related life [14,96]. This result may reflect a low frequency of shared meals in dual-earner couples [13,17,97], which is associated with time constraints, in particular for full-time employees [98] and also in dual-earner couples with conflicting work schedules [13]. Low family meal frequency has been related to unhealthy eating habits [13,97], as well as with lower levels of satisfaction with food-related life [14,62]. However, satisfaction with food-related life is about eating habits but also family interactions around mealtimes [14,21]. Research shows that family meals are an opportunity for family members to interact in a positive manner, providing emotional support and strengthening relationships with one another [60,61]. It can be thus hypothesized that when the frequency of family meals is low, as occurred in this sample, probably due to both partners having full-time jobs, one couple member's satisfaction with food-related life does not cross over to the other members' life satisfaction because they do not share their eating habits [14,96], nor do they experience the affective dimension of meals frequently [60,61]. However, further research is needed to explore the underlying causes of the lack of crossover in dual-earner couples, for example, comparing dual-earner couples with couples in which only one partner has paid employment, as well as including the work schedules of each partner. Although most spillover associations were stronger than crossover associations in the relationship between the three domains of satisfaction and overall life satisfaction, the gender comparison suggests that gender differences are domain-dependent. While similar patterns for women and men were found in the relationship between satisfaction with family life and overall life satisfaction, different gender patterns may exist in the relationship between job satisfaction and overall life satisfaction as well as between satisfaction with food-related and life satisfaction in dual-earner couples. Therefore, our results are consistent with the findings reported by Yucel and Latshaw [73] in that gender differences in spillover and crossover relationships are associated with the variables under study. In the present study, the different gender patterns in the job and food domain are partially related to traditional gender roles, as we discuss below. Our results show similar patterns for women and men in the relationship between satisfaction with family life and overall life satisfaction; i.e., although both couple members' satisfaction with family life significantly crossed over to the other partner's life satisfaction, the spillover association between each member of the dyad's satisfaction with family life and life satisfaction was significantly higher than the crossover associations. This means that both partners' life satisfaction is more susceptible to their own satisfaction with family life than to their partner's. The higher spillover than crossover in women was an expected result, given that the primary domain for women is the home and family [26,70,74,98]. However, contrary to what was hypothesized, the same results were obtained for men. Although, as previously discussed, this result may be associated with Latin American culture [95], this finding may also reflect men being more actively engaged in family issues, as it has been reported in dual earner-couples in different countries [97,98]. This increases their involvement in the family domain, which in turn may lead to satisfaction with family life, a strong contributor to their overall life satisfaction. However, future research should test these findings in other Latin American countries. This is important, given that this finding may indicate a shift to more egalitarian gender roles, at least in the family domain in Latin American countries. In the job domain, while a man's life satisfaction association with his own job satisfaction was higher than the association with the woman's job satisfaction , a woman's life satisfaction was equally associated with her own job satisfaction and her partner's job satisfaction . This means that men's life satisfaction is more susceptible to their own job satisfaction than their partner's job satisfaction, whereas women's life satisfaction is equally susceptible to their job satisfaction as well as their partner's job satisfaction. These findings confirm the relevance of the work role for man's identity [74], but it also expands the relevance of this role for both members of the couple. In fact, it has been reported that men's main family role is being the breadwinner and their paid work is a way to prove their masculinity [99], more so in cultures with predominantly a traditional masculinity framing [100], as is the case in Latin American countries. By contrast, in the food domain, while the woman's life satisfaction association with her own satisfaction with food-related life was higher than the association with the man's satisfaction with food-related life , men's life satisfaction was equally associated with their own satisfaction with food-related life and their female partner's satisfaction with food-related life . Although for women and for men, crossover associations were non-statistically significant, the gender comparison indicates that men's life satisfaction is equally susceptible to their own satisfaction with food-related life as well as to their female partner's satisfaction with food-related life, whereas women's life satisfaction is more susceptible to their own satisfaction with food-related life. This finding may be due to the gendered nature of food preparation. Despite advances towards gender equality in relation to food-related household work in countries around the world, the evidence shows that women invest more hours in the kitchen than men [101] and are the main ones responsible for the food-related tasks and family meals, even if they have paid employment [56]. Therefore, as satisfaction with food-related life also involves planning meals, shopping and preparing meals [58], it can be expected that if women can perform as well at work as in food-related tasks, their self-confidence may be reinforced, positively influencing both their satisfaction with food-related life and with their overall life. In this regard, a recent study stressed the importance for women of the availability and access to enough and healthy food to prepare family meals, which seems to be a key factor for women's satisfaction with food-related life [37]. The limitations of this study should be acknowledged and corrected in future research. The first limitation is the study's cross-sectional design, meaning that causal relationships between variables cannot be established. Longitudinal designs in future studies will allow to test for causality. The second limitation is that all data were self-reported and participants' responses may have been affected by social desirability. A third limitation is the non-probabilistic sampling. This sample was representative of the socioeconomic status distribution in Chilean population [81] but it was not representative in terms of the participants' age, number of family members or children per family. The average number of family members and children per family was higher than the average for Chilean families [102]. Therefore, future studies should include representative samples in terms of Chilean family composition. Moreover, dual-earner couples in this study were parents of adolescent children, so the findings cannot be generalized to families at other stages of the life cycle. Related to the previous limitation, cross-cultural analyses are needed to include diverse Latin American countries, as well as countries with differences in family structure and gender equality, given that culture affects the contribution of life domains to overall life satisfaction [4,5,12] and the influence of gender roles [103]. Another limitation is that part of the crossover effects, and spillover effects that mirror those of the partner, may be explained by homogamy; that is, individuals' tendency to become partners with or marry others with whom they share positive traits, such as happiness and life satisfaction [104]; further studies should address this potential confounding between transmission of experiences and shared traits. One last limitation is that we assessed the spillover and crossover associations only between three life domains and overall life satisfaction; therefore, future studies should include other important life domains, such as financial situation, health, leisure, living arrangements, friends and others. Future research should also explore possible moderators of these associations, not only in samples including dual-earner couples but also in parent-child dyads. Despite these limitations, the results of the present study expand the understanding of how satisfaction in different life domain contributes to the individual's overall life satisfaction by analyzing spillover and crossover associations in dual-earner couples on the basis of the SCM [28]. These results provide practical implications for dual-earner couples, policy makers and organizations. Although the spillover association between satisfaction with family life and life satisfaction was stronger than crossover associations, both couple members' life satisfaction also increases if their partners are more satisfied with their family life. Therefore, both members of the couple should be concerned with the other partner's satisfaction with family life and promote a healthy interaction between the two of them. At the same time, policy makers may develop strategies to enhance dual earner-couples' satisfaction with family life, such as promoting flexibility and perceived control over one's own schedule in employees [17], which would give both members of dual-earner couples enough time to fulfil their family's responsibilities. Organizations should also seek to promote job satisfaction in employees of both genders, with special attention to male employees, given that their job satisfaction not only enhances their own life satisfaction but their female partner's as well. Results from the present study also have important research implications. Studies on the relationship between domain satisfaction and overall life satisfaction have traditionally focused on individual household members. As most life domains involve activities and situations that take place in a social setting, this seems a limited scope. This study supports the use of APIM for modeling and analyzing such interdependencies, while showing that relationships between both members of dual-earner couples in life domains can help increase their life satisfaction. Thus, although dyadic sampling entails methodological and practical difficulties for researchers, more studies about the relationship between satisfaction in life domains and overall life satisfaction should consider the influence that individuals exert on others with whom they share a meaningful relationship. --- Conclusions Our results show that, via spillover, greater job satisfaction, satisfaction with family life and satisfaction with food-related life translate into higher levels of overall life satisfaction in both members of the dyad. Regarding crossovers, as it was hypothesized, a bidirectional crossover was found from one couple member's satisfaction with family life to the other member's life satisfaction. In the job domain, contrary to expectations, only a unidirectional crossover from men's job satisfaction to their female partners' life satisfaction was obtained, while in the food domains, no crossover associations were detected. Taken together, these findings suggest that family life has a more uniform influence on the life satisfaction of both men and women in a couple, followed by non-reciprocal associations from the job domain, and with food-related life limited to having an impact on life satisfaction at an individual level. Therefore, our results show that an individual's life satisfaction may not only be influenced by their own satisfaction in a life domain, as the life satisfaction bottom-up approach poses [2,3], but it may also be influenced by their partner's satisfaction in the same domain, in accordance with the Interdependence Theory [22] and the Family Systems Theory [23]. In addition, our results contribute to the knowledge about gender similarities and differences in the relationship between domain satisfaction and overall life satisfaction in dual-earner couples, showing, at the same time, different patterns in spillover and crossover associations in the job and the food domains. Some findings aligned with expectations, such as that men's life satisfaction was associated with their own job satisfaction more than with their female partners' job satisfaction; women's life satisfaction was associated with their own family and food-related life satisfaction more than with those from their male partners. Other findings did not support the hypotheses, such as that men's own family life was more strongly associated with their own life satisfaction than women's satisfaction with family life . Moreover, no statistical differences were found between spillover and crossover associations for job satisfaction in women and for satisfaction with food-related life in men. Because the contribution of life domains to overall life satisfaction is culture-sensitive [4,5,12], however, further research is needed in countries where the relationship between different-sex couples is more egalitarian. --- Publisher's Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

The aim of this study was to examine spillover and crossover effects between job satisfaction, satisfaction with family life (SWFaL), satisfaction with food-related life (SWFoL) and overall life satisfaction (LS) in dual-earner couples. The gender of the couple members was also accounted for in these interrelationships. A sample of 473 dual-earner couples with adolescent children in Temuco, Chile, responded to a questionnaire. Both members of the couple answered the Satisfaction with Life Scale, Overall Job Satisfaction Scale, the Satisfaction with Family Life Scale and the Satisfaction with Food-related Life Scale. Using the Actor-Partner Interdependence Model and structural equation modeling, it was found that men's LS was positively associated with their own job satisfaction, SWFaL and SWFoL (spillover), as well as with their partner's SWFaL (crossover). Results also showed that women's LS was positively associated with their own job satisfaction, SWFaL and SWFoL (spillover), as well as with their partner's SWFaL and job satisfaction. Different gender patterns were found for job satisfaction and SWFoL. These findings suggest that for dual-earner couples, life satisfaction may not only be influenced by their own individual satisfaction in a life domain but also by their partner's satisfaction in the same domain.

Between 1347 and 1351, much of the European population died by the Black Death . In desperation, physicians, religious authorities, and the common folk adopted various practices to ward off infection. Recommendations included burning incense, bathing in human urine, applying dried toads to lesions, or self-flagellation . These practices reflected theories about the origins of the disease, some of which blamed Jews for poisoning wells. As a result, xenophobia emerged and Jews and other stigmatized groups were persecuted across Europe. For example, on 14 February 1349, inhabitants of Strasbourg killed 900 Jews from that city . This example illustrates two recurrent social phenomena associated with mass disease outbreaks: a collective effort at making sense or symbolically coping with the disease threat and devising means of protection, and blaming and persecution of specific groups such as minorities or foreigners for the disease . This example remains relevant today. Many studies have documented how disease threat leads to avoidance or stigmatization of out-groups . At least two prominent research traditions in social psychology have studied out-group blame and avoidance due to disease threat. A social representations approach proposes that people make sense of disease threat by means of socially constructed beliefs. An important function of these beliefs is to symbolically protect the in-group by distinguishing it from the out-group . The distinction is used to blame out-groups for causing or spreading disease, be it by a lack of hygiene , education or self-control , or by primitive sexual or cultural practices. Evidence of this process of symbolic othering can be found at many levels. Since the middle ages, the nation has been an important category for constructing otherness in terms of disease spread. This is evident in the way diseases are named. In the 15th century, syphilis was variously referred to as 'French pox' , morbus Germanicus , or 'Chinese disease' . Othering along national lines is also evident in the way cultural practices of other nations are depicted as an explanation for a disease. For instance, the Severe Acute Respiratory Syndrome epidemic was described in the British media as being caused by unhygienic Chinese cultural habits, such as dirty markets, close proximity to animals, or the habit of spitting on the ground . The Ebola outbreak was also associated with Africa or African culture in the media . An evolutionary approach explains inter-group phenomena, especially prejudice and avoidance, as an evolved adaptation to protect individuals from disease threat . Disease has always represented a threat to human survival. Consequently, humans evolved behavioural tendencies to avoid people likely to transmit diseases, such as out-group members. Because of the potentially high costs of infection, mechanisms have evolved to extend avoidance to generalized out-groups such as foreigners . Moreover, there exist individual differences in perceived vulnerability to disease and more particularly in people's aversion to germs . These individual differences predict negative attitudes towards immigrants . In addition, the evolutionary approach has shown that contextually aroused perceptions of disease threat trigger xenophobic responses, even when the threat is unrelated to foreign out-groups . However, demonstrations of contextual effects typically rely on manipulation of disgust-evoking stimuli or disease salience and are unspecific as to when during an epidemic threat perceptions are likely to be high. Taken together, research from both the social representations and evolutionary approaches demonstrate the ubiquity of the link between disease and out-groups, especially national out-groups, despite the existence of authoritative scientific discourses explaining the origin of infectious diseases through natural causes. However, less attention has been paid to collective symbolic coping with disease threat. We argue that inter-group phenomena like othering are fed, at an ideological level, by mass media reporting of the disease and, at an individual level, by the uncertainty caused by the diffusion of information. To explore this process, we applied the model of CSC to the recent outbreak of avian influenza . --- Collective symbolic coping: How people make sense of collective threats The CSC model describes how groups make sense of novel situations that threaten the social order. Anchored in social representation theory , it emphasizes the collective dimension of the term coping . CSC involves the construction and diffusion of representations about a new collective threat, often through mass media. These representations provide individuals with ways of interpreting and dealing with the new threat. CSC occurs in four stages. First, during the awareness stage, the new situation emerges as an issue through media agenda setting . Second, intensive communication leads to a divergence stage during which multiple frames or interpretations emerge, creating ambiguity, and uncertainty about origins of the new situation. In the third stage, convergence, a dominant discourse emerges that decreases uncertainty. In the fourth stage, normalization, the explanation of the event is integrated into common knowledge, becoming more mundane. This model is useful for describing sense-making processes in the face of different threats to the social order. According to the few existing studies , increases in intensity of coverage and multiple interpretive frames are typical of the awareness and divergence stage . Less is known about convergence and normalization. Convergence could be detected through decrease of media coverage and of inconsistent frames. But, normalization seems to be a complex, long-term process that can sometimes last for decades . The CSC model has only been studied for threat related to biotechnology. Here, we extend the model to the domain of emerging infectious diseases. These diseases represent not only a physical but also a symbolic threat to the social order . For example, AIDS threatened many established ideas including the notions of safe and unsafe sexual practices . It also seems plausible to assume that collective sensemaking of emerging infectious diseases evolves over time. For AIDS again, following its initial emergence in 1981 , the disease was indeed characterized by multiple interpretations . These included rumours , theories attributing blame to deviant groups such as gays, or conspiracy theories implicating governments or scientists . Since the mid-1980s, an official public discourse on AIDS has emerged in Anglo-Saxon countries , suppressing other deviant discourses such as denialism . The emergence of an official discourse corresponds to the convergence stage of CSC. Finally, AIDS is in a process of normalization since 1996 , characterized by banalization in public discourse, and decreased perception of threat -also consistent with the normalization stage of the CSC model. In this paper, we document awareness and divergence stages of CSC relative to the AI outbreak. These stages are characterized in the media by an increase of coverage for the awareness stage, and a multiplicity of frames, or themes, that induce ambiguous or uncertain perspectives on events, during the divergence stage. In the case of AI, the pandemic failed to materialize, and no consensual explanation emerged about its origins, modes of transmission, and protection against it, possibly increasing uncertainty and suspicion about potential man-made causes of the disease . We therefore surmise that the divergence stage, by creating multiple discourses about AI and thus multiple interpretive frames, could cause a feeling of uncertainty in individuals that is reduced by out-group differentiation processes. Uncertain disease threat and out-groups: Othering as symbolic coping Some stages of CSC , by creating uncertainty, trigger an increased need for symbolic protection against the threatening event. Uncertainty favours the emergence of coping strategies like othering. This idea is supported by the subjective uncertainty reduction model derived from self-categorization theory . This model states that reducing uncertainty and sensemaking are two strong motivations in people's life. Uncertainty is an aversive state reducing the perception of personal control and enhancing negative feelings such as fear. Uncertainty arises when people perceive disagreements and dissensus in their group. People try to reduce uncertainty by accentuating group identification or increasing inter-group differentiation . The subjective uncertainty reduction model can thus specify the CSC model. The divergence stage of CSC is typically characterized by ambiguity and uncertainty due to multiple interpretive frames. We therefore hypothesize that inter-group differentiation strategies like othering are more likely to arise in this stage than others. However, the relation between uncertainty about disease risk and othering may not always be direct because individuals vary in their chronic feelings of uncertainty. The relation may depend on individual differences in feelings aversion to germ as well as ideological beliefs. For example, germ aversion predicts implicit cognitions about out-groups and danger. Thus, people high in GA should react to uncertainty by manifesting more othering than people less aversive to germs. Social dominance orientation is an ideological belief characterized by support for group-based hierarchical differences in society. Individuals high in this belief can be expected to tend to reinforce the symbolic distinction between subordinate germ-carrying out-groups and the dominant -clean and healthy -in-group members in case of uncertain disease risk. In summary, we suggest that othering is more likely to occur when mass media coverage of the disease is the highest and when multiple representations of the disease create uncertainty, that is, during the divergence stage of CSC. According to the subjective uncertainty reduction model, people try to reduce uncertainty by increasing inter-group differentiation strategies like othering in the case of disease threat. But, this strategy should be reinforced by chronic individual differences in GA and ideological beliefs such as SDO. --- Our studies Our research is grounded in AI, described by the World Health Organization as one of the most dangerous emerging infectious diseases of the 21st century . The H5N1 strain is a particular challenge for global public health because it has crossed the species barrier and may mutate, provoking a pandemic. Although animal-human and human-human transmission is currently limited, AI represents a major threat due to its high mortality . Since 1997, several outbreaks of H5N1 have occurred in Asian countries such as Vietnam, Thailand, or Indonesia. In July 2005, the virus spread to Europe. We studied the period following initial infections in birds in Europe, from September 2005 onwards. As an emerging infectious disease, AI represents a new material and symbolic threat the public needed to cope with. We conducted two studies. In Study 1, we extended the CSC model to AI by analysing media coverage about the disease between Fall 2005 and late Spring 2007. The model predicts an initial increase in media coverage of AI , then more thematic diversity in coverage followed by a decrease in coverage and thematic diversity . Given that the normalization stage could take years, we had no expectations about this stage for AI. In Study 2, we link uncertainty occurring during the divergence stage of the CSC with othering. We measured othering tendencies in a two-wave repeated cross-sectional survey, with Wave 1 in June 2006 and Wave 2 in June 2007. Comparing othering between Waves 1 and 2 creates a natural control for the effect of the awareness stage of CSC on othering. We also analysed the moderating impact of GA and SDO on othering at both waves. We operationalized othering by asking respondents to indicate whether countries had experienced human cases of AI . Assigning human cases to foreign countries can be interpreted as a way of distancing oneself from such countries and its inhabitants, labelling them as 'contaminated'. We expect that at Wave 1, uncertainty would particularly affect participants high in GA and in SDO and would induce them to generalize AI to foreign countries, that is, to assign more human cases of AI to foreign countries than participants low in GA and SDO. This should not be the case at Wave 2, when uncertainty had decreased. --- STUDY 1: AI IN THE MEDIA Study 1 investigated the time course and textual structure of media coverage of AI between September 2005 and June 2007. The time course analysis measured fluctuations in AI coverage. Text analysis explored the topical diversity of coverage over time, diversity being an indicator of multiple approaches of the disease and thus of divergence. Taken together, these analyses allow us to document CSC stages . --- Method --- Materials One hundred and seventy-eight articles were selected from the Lexis-Nexis database. The selection was restricted to articles published on AI in 20 French-speaking European newspapers or press agencies between September 2005 and June 2007. We also restricted the search to articles about five main geographical areas concerned by AI: Africa, Asia, Eastern Europe, Middle East, and Western Europe. Multiple instances of the same article were eliminated. We first analysed the time course of media coverage, that is, the number of articles published each month between September 2005 and June 2007. We then conducted a computer-assisted text analysis using the Alceste software package on the 178 articles, identifying discourse classes and their associations with specific temporal periods. --- Computer-assisted text analysis Following the CSC model, we expected temporal changes in the thematic diversity of media coverage of AI. To avoid problems associated with reliability and validity of classical content analyses, in particular coding biases , we applied automatic textual classification to the corpus using Alceste. The software first creates a reduced dictionary after lemmatizing words . Conceptual words with a minimum frequency are active words in the analysis and are separated from passive words such as articles or connectors. The first step of the analysis is segmenting texts into socalled Elementary Contextual Units corresponding approximately to one or two sentences . ECUs are then grouped into a number of classes using the co-occurrences between active words. A class must contain at least 5% of ECUs. To check the validity of the classification, two hierarchical descending cluster analyses are then conducted by changing the number of active words per ECU. If the two analyses reveal a similar pattern of clusters, a final classification is built by retaining the overlapping ECUs of both clusters and excluding the others. This is the main product of the Alceste analysis. Interpretation of the results, that is, naming the classes, is guided by the words and ECUs significantly associated with each class. The strength of the typical words and ECUs of each class is determined by a chi-square statistic, estimating the deviation of the word's frequency in a class from a random distribution of all words among all classes . One then obtains a specific dictionary of the typical and anti-typical words for each class. Alceste also identifies typical ECUs of a class. Finally, Alceste allows to examine the link between classes and the modalities of passive variables characterizing each text. In our case, publication date as well as the name of the newspaper was introduced as passive variables. Each article is entered with its publication date and the name of the newspaper it was published in, so that each ECU of the article is associated with this information. A chi-square statistic is also calculated to estimate the deviation from a random distribution of the associations between each modality with each class. The first peak corresponds to reports about the arrival of infected birds in Europe. The second peak corresponds to reports about the discovery of AI in an increasing number of European countries . Even if H5N1 has been known since 2003 for its serious consequences for animals and humans, it was limited to Asian countries. In October 2005, the WHO confirmed first animal cases of H5N1 in Turkey, Romania, and the United Kingdom . So, the first peak in Figure 1 corresponds to the awareness stage of CSC, during which a novel event acquires widespread relevance through media amplification . The second peak could constitute the divergence phase, characterized by more coverage, and an increase of thematic diversity. Finally, the decrease and stabilization of coverage between May 2006 and June 2007 could constitute a convergence stage. The last peak in February 2007 corresponds to the emergence of some new cases of AI among wild birds and poultry in Europe, mainly in Great Britain and so to a reactivation of threat about AI. --- Results --- Time course analysis --- Textual analysis: Descriptions of classes The time course data are not, in itself, a demonstration that media coverage of AI followed CSC stages. The text analysis provides more evidence. Alceste identified 1,347 different active word types with a minimal frequency of seven, representing a total of 45,488 words distributed in 2,981 ECUs. The hierarchical descending cluster analysis classified 2,143 ECUs into six classes after a first differentiation between two clusters, one composed of two and the other of four classes. We named the classes based on their most typical words and ECUs. Table 1 presents a summary of the results in terms of each class and its typical words, anti-typical words and typical ECUs. The two classes of the first cluster concern reports on actions of international organizations and governments to face a disease outbreak. Class 1 was named Medical coping strategies. It describes how countries would take steps to check a potential outbreak by constituting stocks of vaccines or buying medicine from pharmaceutical firms. Numerous action verbs describe intense activity of governmental health agencies to organize prevention and protection of the population. Class 2 was named International financial strategies . It describes AI as an international problem that countries have to mobilize against via financial and economic actions designed to collect funds for international organizations. Typical ECUs describe conferences where leaders and experts of these organizations emphasize the need for financial means to face the disease and to help poor countries, in particular African countries such as Nigeria and Niger. Discourse in these classes does not evoke the factual and concrete aspects of AI, which constitute the essential content of the other four classes. The repeated announcement by the WHO of the threat of a pandemic is significantly less frequent among all classes of the second cluster, as are evocations of medical coping. Class 3 concerns measures imposed by authorities to protect farms and to prevent disease transmission through migrating birds or food consumption. We labelled it Protection against food risks . The content is organized around the control of farmyards and ornithological parks imposed by authorities in different geographical areas of European countries. The population is encouraged to adopt safety rules . Few references are made to cases of infected animals. The opposite is true for Class 4 named Infected birds in Europe . Content focuses on cases of wild birds infected by H5N1 and found dead in both Western and Eastern Europe. The information appears as precise reports about the type and the number of birds infected, as well as the locations and the dates of their detection. In a similar but more dramatic vein, Class 5 was named Human cases outside Europe . Typical ECUs enumerate victims of AI in four countries and also evoke other Asian Countries . They report the characteristics of the victims and the circumstances of the diagnosis of symptoms. Class 6 was named Virus transmission modes and concerns transmission of AI from animals to humans, focusing on living conditions of people in Asian countries. Different paths of contamination are discussed depending on possible virus mutations. There are also references to the probability of contamination due to proximity between infected animals and humans, as in families of Asian victims. --- Textual analysis: Association with temporal periods At this point, results show that newspapers cover a wide range of topics from the simple count of dead birds in Europe, to the elaboration of financial strategies to face a disease outbreak. Linking these results and CSC stages requires an analysis of the association between classes and temporal periods. Table 2 presents the distribution of the ECUs by class and by month between September 2005 and May 2007. On the basis of this distribution, Alceste computes signed chi-square tests with one degree of freedom indicating, for each month, significant presence or significant absence of classes . In the autumn months of 2005, media coverage is dominated by an official discourse of medical experts about coping with the imminent disease outbreak . Coverage decreases in December 2005. In January, February, and March 2006, we observe increases of all classes except Class 1. This starts with reports on human victims in Asia and issues of virus transmission in January, continuing with infections of birds in Europe and protection measures against food contamination in February and ending with international funding in March . These data suggest that thematic diversity increased during the second peak in media coverage from January to March 2006. We also observe a rapid decline of all classes until the last small peak in February 2007 following the announcement of new human victims. Only Class 1 is present at the end of the time course . The message about pharmaceutical measures against an outbreak remained but was treated with skepticism in the rare newspapers still reporting on AI. --- Discussion Taken together, our results suggest that the awareness and divergence stages described by Wagner et al. can be documented for the 2005-2007 AI outbreak. Awareness appears when the problematic event first emerges in media discourse. Our evidence of this stage comes from the first peak between September and December 2005. The media discourse translates concerns derived from expert opinion. It remains abstract, without reporting about concrete aspects or effects of AI. Divergence is characterized by high media coverage and emergence of discussions and debate reflected in a multiplicity of topics. In our data, a second peak appeared between January and March 2006. The discourse becomes more concrete and varied by reporting recommendations for avoiding food contamination , factual descriptions of human and animal AI victims , and related issues such as transmission , while retaining a focus on international financial issues . The presence of these classes shows that the issue of AI became considerably more complex during this period. From this evidence, we conclude that the period between January and March 2006 corresponds to a divergence stage. There is little evidence for a convergence stage. It seems that when a tangible threat failed to materialize, the media simply stopped covering AI. However, we observed that Class 1, medical coping strategies, remains the only theme present at the end of the period we analysed. Finally, we note that words, such as death, worried, security, safety, or risks, are associated with classes linked with the January to March 2006 period. Our findings have an important limitation. The temporal dynamics we take as evidence for divergence could be a side effect of increased coverage of a topic in general , rather than a specific effect of threat in particular. More research is needed to deal with this issue, which we expand upon in the General Discussion. However, increased knowledge about an unfamiliar topic may be viewed as being, in and of itself, threatening, because such novel knowledge creates uncertainty and needs to be integrated in common sense. In this way, it is the emergence and coexistence of multiple discourses about a topic that creates uncertainty and thus threat, and not only the content of the knowledge. That is why we expect the divergence stage to lead to an increase in uncertainty and individuals' perceptions of threat in early 2006 and to the mobilization of inter-group beliefs to cope with it. We investigated this in Study 2. --- STUDY 2: CSC STAGES, THREAT PERCEPTION, AND OTHERING Study 2 explored links between the uncertainty occurring during the divergence stage and othering. We conducted a two-wave repeated cross-sectional survey. Wave 1 took place in June 2006 at the end of the peak of media coverage . Wave 2 took place in June 2007 when media coverage had decreased. We measured othering in terms of the generalization of threat to national out-groups, that is, the number of foreign nations perceived as afflicted with human cases of AI. Participants indicated that countries, from a list of 15 countries from five geographic regions , had experienced human cases of H5N1. The geographic regions were identical to those included in Study 1. Furthermore, countries were chosen according to two criteria: they had documented cases of AI in birds that varied in media coverage, and they had not experienced human cases. Thus, participants' choices reflected their knowledge of information diffused by media about countries and their representation of the geographical boundaries of AI spread. Indeed, as Study 1 showed, the media often depicted the spread of AI in terms of foreign nations. Moreover, media representations of the spread often used maps as visual aids. Geographical location thus constitutes an objectification of disease threat, that is, as a symbol of threat coming from outside. As shown in Study 1, the divergence stage is characterized by an increase of information on the geographic evolution of victims of AI , the proximity of the danger and the unsolved question of the virus transmission from animals to humans. People are thus subject to an uncertain symbolic context that should facilitate othering reactions. We expected that during this divergence phase , people should tick more foreign countries on average when they are more aversive to germs. Moreover, the othering process should increase when the GA is coupled with a high endorsement of a hierarchical view of society . After the divergence stage , high SDO and high GA should not lead to more foreign countries being ticked. We thus expected a three-way interaction between Wave, SDO, and GA on the mean number of foreign countries ticked. In Study 2, we also checked that participants are sensitive to the prevailing media context, and, at the same time, that the effects of our independent variables on othering are not simply artefacts of media coverage. Indeed, participants can be expected to tick countries that are frequently mentioned in the media more often than countries that are not, simply because such countries are better available in memory . We thus distinguished different measures of othering as a function of whether countries were frequently mentioned in the media or not. We expect the above-mentioned three-way interaction between Wave, GA, and SDO to hold especially for countries less frequently mentioned in the media. --- Method Participants and procedure Four hundred and forty-two Swiss students were surveyed on a voluntary basis on their perceptions of AI. One hundred and ninety-three answered in June 2006 and 249 in June 2007. Mean age was 22.3 years and 71.5% of the sample were women. --- Measures To assess GA, we used the relevant subscale of the Perceived Vulnerability to Disease scale . GA is negatively linked with pro-immigrant attitudes . Moreover, it interacts with ideological orientations to determine out-group avoidance phenomenon as a reaction to disease threat . Participants completed a short version of the GA subscale . A mean score was computed on the items and subsequently centred. Higher scores indicate more GA. We measured SDO via a six-item scale drawn from Pratto, Sidanius, Stallworth, & Malle . A mean score was computed on the items and subsequently centred. Higher scores indicate higher SDO. The othering dependent variable was computed from a list of 15 countries from five regions . Participants ticked countries they believed to have experienced human cases of H5N1 infection . In fact, none of the countries had actually experienced human cases. Four othering indicators were constructed by dividing the 15 countries into four groups on primarily geographical grounds and calculating the mean rate at which countries in each group were ticked. The Asian group comprised Japan, Malaysia, and the Philippines , and the African group comprised Kenya, Senegal, and Zimbabwe . The nine remaining European and Middle Eastern countries were divided into those frequently mentioned in the media , namely Austria, Bulgaria, Iran, and Spain , and those infrequently mentioned, namely Albania, Norway, Saudi Arabia, Slovakia, and Syria . This division was done because preliminary analysis showed that the ticks participants gave these countries in Waves 1 and 2 correlated with their media mentions in Study 1. --- Results Participants indicated their age, gender, preoccupations about AI, and university affiliation. Preoccupations about AI were measured through three items that were subsequently averaged. Age, gender, and preoccupations did not affect the dependent variables, nor did they interact with the predictors. They were thus removed from analyses. University was entered as a control in the analyses. The dummy variables did not interact with predictors for all indicators except for Africa. For this measure, university, GA, SDO, and wave interacted . We thus do not interpret analyses for Africa and we removed the dummy university variables in the analyses of the three remaining othering measures. The same multiple linear regressions were conducted on the three dependent variables with SDO, GA, Wave, and their interactions as predictors. Before performing analyses, we checked that GA and SDO did not vary as a function of Wave = 0.13, ns; SDO: F = 2.03, ns). For the othering score of Asian countries, only the effect of Wave was significant. As mentioned above, participants ticked more Asian countries at Wave 2 than at Wave 1. For frequently mentioned countries, there was a significant interaction between SDO and GA, indicating that participants high in GA ticked more countries, but only when they were high in SDO . The interaction between GA and Wave is also significant, showing that the impact of Wave was not significant for people high in GA but was significant for people low in GA, who ticked more countries at Wave 2 than at Wave 1 . These effects were qualified by the marginally significant expected three-way interaction between Wave, SDO, and GA. As expected, the interaction between SDO and GA was significant only at Wave 1 . Slope tests indicated that for people high in GA, SDO had a marginal impact on ticked countries . For people low in GA, SDO significantly decreased the number of countries ticked . The interaction between SDO and GA did not hold at Wave 2: . For less frequently mentioned countries, there was a significant main effect of GA, indicating that people high in GA ticked more countries than those low in GA. A significant GA by SDO interaction indicated that GA increased the number of ticked countries, but only for participants high in SDO and not for participants low in SDO . The GA by Wave interaction was significant, showing that the impact of Wave was not significant for people high in GA but was significant for people low in GA, who ticked more countries at Wave 2 than at Wave 1 . The expected three-way interaction was significant and showed that the interaction between SDO and GA was only significant at Wave 1 and not at Wave 2 . Slope tests indicated that for people high in GA, SDO significantly increased the number of ticked countries . On the contrary, for people low in GA, SDO had no impact on the number of countries ticked . --- Discussion Study 2 aimed at extending past results about disease threat perceptions and othering, predicting the temporal occurrence of othering using the CSC model. We measured othering by the mean number of foreign countries of different regions perceived as having experienced human cases of AI. Controlling for the frequency with which countries were mentioned in the media, we found that othering was higher during Wave 1 than Wave 2, but only for participants high in GA and SDO. Moreover, we observed this effect was stronger for countries less frequently mentioned by the media. This finding supports our claim that the divergence phase of CSC creates uncertainty that people try to reduce via out-group blame processes like othering. For Asian countries, only Wave affected othering. This suggests that perceptions of human infections in these countries are directly tied to the media climate prevalent just before Wave 1, that is, the divergence phase, and were reinforced during the time following this phase. Note that Asia is the only region where participants do not differentiate the countries by taking into account their frequency of mention in newspapers. We note that this geographic area was mentioned more often in the newspapers in Study 1 than the others . Actually, 86% of participants ticked at least one Asian country compared with 18% for Western Europe, 32% for Eastern Europe, and 13% for Middle East. Thus, participants apparently perceived less ambiguity concerning Asia than concerning other geographical areas. An unexpected result emerged from the marginally significant three-way interaction on the frequently mentioned countries. SDO marginally reinforced othering among people high in GA, but significantly decreased the number of ticked countries for people low in GA. This result could reveal that participants with high SDO use less media information in their judgment and consequently react to uncertainty by minimizing the danger in foreign countries when they are low in GA and exaggerate it when they are high in GA. Indeed, differences between the numbers of more and less frequently mentioned countries ticked tended to decrease at Wave 1 when SDO increased, as shown by an additional regression analysis on this score . Except for Asia, interactions between GA and Wave and between SDO and GA were significant irrespective of how often countries were mentioned in the media. These interactions suggest that both evolved and cultural processes are not independent of each other but interact as part of a more global process . Finally, they feed the debate around the idea that purportedly evolved individual differences, such as GA, are context dependent to some degree. Finally, results showed that both contextual conditions and ideological preferences are necessary for people to perceive a disease threat as coming from 'outside' . --- GENERAL DISCUSSION Social psychologists have studied individual-level out-group blame and avoidance processes involved in coping with disease threat . The CSC model offers a complementary perspective, describing stages by which public discourse leads to a collective representation of a threat . But, it does not explain how these stages affect individual-level processes, in particular how the symbolic environment activates collective beliefs leading to inter-group phenomena like othering. The results of the present studies contribute substantially to articulating these two perspectives. Study 1 suggests that the CSC model may be applicable to the domain of disease threat. We documented an awareness and a divergence stage. In Study 2, people feeling averse to germs and supporting a hierarchical view of society attributed human cases of disease threat to more foreign countries. We discuss implications of these findings and limitations of our study. --- Implications for CSC The CSC model is applicable to the domain of emerging infectious diseases. This domain and the original CSC domain of biotechnology are similar in that they involve complex and controversial scientific knowledge that is potentially threatening to the established social order. However, while our findings converge with previous studies on CSC, there are also important differences. We found evidence for CSC stages of awareness and divergence in media coverage of the AI outbreak. But unlike Wagner et al. , we could not observe a convergence or normalization stage. There may be several reasons for this. First, it may have been too soon to observe them. As a new disease, AI may not have had time to converge and normalize in the media. Alternatively, AI may have entered a paradoxical normalization stage. This term has been used for AIDS to describe the discrepancy between the public's perception of risks and the epidemiological reality of the disease. Current medical treatments have transformed AIDS from a predicted catastrophe into 'a problem that can be managed by public health and medical care' ), leading to decreased risk perceptions. AI is arguably in a similar situation: a predicted catastrophe has failed to materialize, thus leading to a decreased perception of risk in the public and in the media. This situation may have been exacerbated by the repetition of this scenario during the 2009 H1N1 outbreak, which also was announced as a potential catastrophe but turned out to be relatively mild. Moreover, the relative frequency at which new infectious diseases occur may also explain why normalization is hard to detect. Representations of previous diseases may be used to anchor understanding of a newly emerging infectious disease in the awareness stage. This difference in findings indicates that more research on different cases of CSC from various domains is necessary to refine the model and better specify the characteristics and variability of the stages. We suggest adopting a case-study approach, analysing dynamics, and contextual aspects of the relation between a specific collective threat and CSC processes. More cases should enable theory building by crosscase comparisons , thus leading to further specification of the CSC model. Such comparisons would allow answering the question whether CSC stages as currently described are specific to events such as disease outbreaks or whether they are a common feature of suddenly occurring threats in general. They may also reveal dynamics internal to each stage, for example, how the thematic diversity and multiplicity of frames postulated to characterize the divergence phase emerges over time. --- Implications for othering Our study has implications for the study of othering as a response to disease threat. We have shown that a particular combination of individual differences in perceived vulnerability to disease , ideological beliefs about group hierarchies , and media context facilitates the perception of disease threat as located among out-groups such as foreign countries. In other words, othering is more likely during certain moments of an outbreak than others. This conclusion is consistent with work suggesting that categorization and in-group protection strategies can be linked to situational uncertainty . The CSC model and the motivation to reduce uncertainty thus offer an explanation of why inter-group phenomena are likely to occur during this stage. Indeed, out-group blame is often anchored in preexisting representations about out-groups . These representations provide symbolic material that may be used during the divergence phase to make sense of the novel, threatening event. For example, attributions of poor hygiene can be used both to anchor a novel disease outbreak in existing representations and to objectify it by means of concrete images such as nations on a map or pictures of wild birds. --- Limitations Study 2 used a student sample, which limits the generalization of our results to the population. Due to the university climate promoting anti-discrimination norms, students often have more tolerant worldviews than the general public . They may be more reluctant to stigmatize out-groups and probably are more exposed to mass media than some other groups. However, there is no reason to suspect that the underlying psychological mechanisms involved in the three-way interactions would differ between students and the general public. Second, in Study 2, we cannot draw firm causal conclusions concerning the impact of uncertainty as this factor was observed but not manipulated. However, we studied CSC, a temporal process that unfolded over several years, which is impossible to manipulate. Thus, the disadvantages of a lack of control over this independent variable are outweighed by the benefits of examining reactions to a real-life health threat. --- Conclusions Despite its limitations, our study constitutes an original contribution to understanding how CSC processes and processes of out-group blame interact. We show that othering is particularly likely during the divergence stage of CSC, when multiple interpretations of a disease coexist, thereby creating a symbolic environment characterized by increased uncertainty. Othering operates to reduce this uncertainty by symbolically associating the disease with out-groups.

Much research studies how individuals cope with disease threat by blaming out-groups and protecting the in-group. The model of collective symbolic coping (CSC) describes four stages by which representations of a threatening event are elaborated in the mass media: awareness, divergence, convergence, and normalization. We used the CSC model to predict when symbolic in-group protection (othering) would occur in the case of the avian influenza (AI) outbreak. Two studies documented CSC stages and showed that othering occurred during the divergence stage, characterized by an uncertain symbolic environment. Study 1 analysed media coverage of AI over time, documenting CSC stages of awareness and divergence. In Study 2, a two-wave repeated cross-sectional survey was conducted just after the divergence stage and a year later. Othering was measured by the number of foreign countries erroneously ticked by participants as having human victims. Individual differences in germ aversion and social dominance orientation interacted to predict othering during the divergence stage but not a year later. Implications for research on CSC and symbolic in-group protection strategies resulting from disease threat are discussed.

Statistical analysis. Time trends and projected prevalences of BMI categories. We examined time trends in the prevalence of BMI categories between 2006 and 2019 according to sociodemographic characteristics and geographic units. BMI categories were defined per the WHO classification: underweight or normal weight , pre-obesity , obesity class I , and obesity classes II and III 11 . We also performed time trend analysis considering the definitions of overweight and obesity . We performed simple Poisson and linear regression models to estimate the relative and absolute increases in the prevalence of overweight, obesity and obesity classes II and III between 2006 and 2019. A simple multinomial logistic regression model was used to predict the prevalence of each BMI category over time from 2006 through 2030. This model ensured the prevalence of all BMI categories adds up to 100% each year, and enables the estimation of a nonlinear trend in the prevalence of BMI categories 6 . In addition, it implicitly considers the demographic composition of the population and the factors contributing to BMI changes over time 6 . Thus, unlike studies estimating the causal effects of exposures on obesity risk, studies predicting BMI over time require no confounding control 6 . Therefore, our simple multinomial logistic regression model included only BMI category and time . Same methodological approach has been used a previous study on projected obesity in US 6 . Regression models were conducted according to sex , age groups , race/skin color , educational attainment and geographic units independently, considering the Vigitel sample weights. We examined time trends and projected prevalence of each BMI category, as well as the prevalence of overweight , obesity and obesity classes II and III . Assessment of prediction accuracy. The accuracy of the prediction model was evaluated via a simple multinomial logistic regression model for BMI categories and time from 2006 to 2013. The predicted prevalence of each BMI category from 2014 to 2019 was estimated according to sex, and compared with the corresponding observed prevalence for that same year-sex. Model accuracy was measured via two metrics. First, we calculated the coverage probability, in which the 95% CI of each predicted prevalence between 2014 and 2019 were evaluated to ascertain whether they included the observed prevalence for that same year-sex stratum. Second, we evaluated whether the difference between predicted and the observed prevalences was lower than 10% . --- Ethics approval. Vigitel was approved by the National Research Ethics Commission, and the identified databases are available at: http:// svs. aids. gov. br/ downl oad/ Vigit el/. --- Results Time trends prevalence of overweight, obesity and obesity class II and III between 2006 and 2019. In 2006, the prevalence of overweight, obesity and obesity classes II and III in Brazilian adults were 30.9%, 8.6%, and 3.2%, respectively. In 2019, the prevalences reached 35.1% for overweight, 14.6% for obesity and 5.7% for obesity classes II and III . The prevalences of overweight, obesity and obesity classes II and III increased in all sociodemographic subgroups between 2006 and 2019 . However, speed and extent of weight gain varied by sex, age group, race/ skin color and educational attainment. We observed a higher relative increase in the prevalence of overweight between 2006 and 2019 in women , young adults , blacks and other minority ethnicities , and adults with 8-11 years of education . Similar pattern was observed for the increase in the prevalence of obesity by subgroups. For obesity classes II and III, the relative increase in the same period was higher in men , middle-aged adults , blacks and other minority ethnicities , and adults with 8-11 years of education . Absolute differences in the prevalence of overweight, obesity and obesity classes II and II between 2006 and 2019 are displayed in the Table 1. --- Projected prevalence of overweight, obesity and obesity class II and III by 2030. The projected prevalences by 2030 are estimated to be 68.1% for overweight, 29.6% for obesity and 9.3% for obesity classes II and III . The prevalence of obesity is estimated to be 30.2% in women and 28.8% in men. Middle-aged adults, blacks and other minority ethnicities, and adults with lower educational attainment are also estimated to have higher prevalences of obesity by 2030 . Northern In 2030, a quarter of the adult population may be living with obesity by 2030 in 24 out of the 27 geographic units. The prevalence of obesity classes II and III is estimated to be higher than 10% in 8 out of 27 geographic units . Predictive accuracy of the model. Our model had a 21% coverage probability . All projected prevalence from 2014 to 2019 showed a relative error lower than 10% in relation to the observed prevalence. Our model showed a 54% accuracy when considered a 5% relative error . --- Discussion In this study, we used data from 730,309 participants from Vigitel to examine time trends and projected obesity epidemic in Brazil between 2006 and 2030. Between 2006 and 2019, we observed a 30% increase in the prevalence of overweight , a 72% increase in the prevalence of obesity and a 76% increase in the prevalence of obesity classes II and III . The prevalences of BMI categories by 2030 are estimated to be 68.1% for overweight, 29.6% for obesity and 9.3% for obesity classes II and III. The obesity epidemic is a global public health concern. In 2016, approximately 1.9 billion adults were living with obesity, and an increasing time trend has been observed in almost every country in the world 1 . Studies on the projected future trajectories of obesity prevalence are scarce in low-and middle-income countries, despite its potential to inform the need for preventive strategies and preparedness of health systems to cope with obesity consequences. The World Obesity Atlas 2022 have recently estimated that 1 in 5 women and 1 in 7 men will live with obesity by 2030 12 . The global projected prevalence by 2030 is estimated to be 17.5% for obesity and 5.7% for obesity classes II and III. In Brazil, their projected prevalence of obesity is estimated to be 33% for women and 25% for men by 2030, which are similar to our findings . Although these findings indicate an increasing obesity epidemic in Brazil, the Brazilian figures are still lower than other countries in Americas and worldwide. By 2030, 1 in 3 men and almost two-fifths of women living in Americas region are predicted to have obesity. The 10 highest projected prevalence of obesity in the Americas region ranged from 47% in US to 32% in Dominican Republic. In the global rank, Brazil is also not listed in the top 20 countries with highest projected prevalence of obesity by 2030 . Nonetheless, the increasing prevalence of obesity in Brazil is a concern as it will increase the burden of non-communicable diseases and its associated costs to the Brazilian Unified Health System 13 . Our findings indicate socioeconomic disparities in time trends and projected prevalence of obesity epidemic in Brazil. Data from 103 countries has also shown that as countries develop economically, overweight rates rise, affecting poorer individuals more markedly 14 . Of note, we observed a higher relative increase in the prevalence of overweight between 2006 and 2019 in women, young adults, blacks and other minority ethnicities, and adults with 8-11 years of education. Similar results were observed for absolute increases in the prevalence of obesity. By 2030, 6 out of 10 adults with lower educational attainment are estimated to be living with overweight. Adults with lower educational attainment and blacks and other minority ethnicities may have an even higher prevalence of obesity classes II to III by 2030, compared to its respective counterparts. In Brazil, educational attainment is a good proxy of socioeconomic status. People without access to formal education or those with < 7 years of education are more likely to have lower socioeconomic status and worse health outcomes 15,16 . These results corroborate the projected prevalence of obesity in the United States by 2030: 55.6% of participants with household income below $20.000/year will be living with obesity vs 41.7% in participants with higher household income . Lower educational attainment was also associated with a higher prevalence of obesity classes II to III in US 17 . These findings suggest that public policies aimed at mitigating obesity inequalities are imperative. Obesity is a major risk factor for several NCDs, such as cardiovascular diseases, diabetes, and several types of cancer 18,19 . In 2019, NCDs were responsible for 55% of the 738.371 deaths in Brazil 20 , of which, 56.1% or 173.207 occurred in adults aged 30-69 years and, therefore, are premature and preventable . The increasing obesity epidemic has contributed to the increasing burden of cancer in Brazil. Approximately 15,000 cancer cases per year are attributable to high BMI in Brazil, and projections suggest that this number could surpass 29.000 cases by 2025 18 , The worldwide increase in obesity will impact the rise of other NCDs. Projections indicate that type 2 diabetes will affect at least half a billion people by 2030 21 . For each 4 kg/m 2 increase in BMI there is a 26% to 56% increase in the risk of ischemic heart disease 22 . In Brazil, overweight and obesity has caused more than 30,000 deaths per year from cardiovascular diseases, cancers and respiratory diseases 23 . Our study has important public health implications. Projected obesity epidemic in Brazil -a middle-income country with limited health care resources -reinforce that primary prevention is pivotal to change obesity trajectories in the country. Our findings also highlight the importance of obesity prevention strategies focusing Overall the whole population, surveillance systems, and prevention research to better evaluate and design public health strategies 24 . Moreover, our results showed that obesity affect more socioeconomically deprived groups, whose tend to have less access to healthcare and worse health outcomes 14 . Therefore, public health policies better directed at preventing obesity and reducing social inequalities may reduce the disease burden for future generations, change the predicted trend, and protect vulnerable individuals. Our predictions assume that no major changes in obesity determinants will take place in the next years. However, since the beginning of the Coronavirus pandemic in 2020, the world has been facing an unprecedent health, economic, and social crises, which disproportionately affect poor individuals and low-to middle-income countries [25][26][27] . Unemployment and inflation have risen in Brazil, and austerity measures have jeopardized funding for social protection, compromising the food and nutrition security of vulnerable groups 28 . Thus, we expect that the impoverishment of the population, alongside the limited economic access to healthy food and physical activity might lead to a sharper increase in obesity rates in the near future 29 . This study has some limitations. Weight and height were self-reported and therefore misclassification of BMI categories may have ocurred 30 . In addition, we used hot deck imputation method due to 8.7% missing data of weight or height. The use of landlines in the survey may have included adults with a higher socioeconomic level than the average population of Brazilian capitals 31,32 . However, BMI results from Vigitel have a high agreement with other nationally representative surveys in Brazil. Similarly, projected obesity epidemic based on adults living in capital cities may not reflect the entire Brazilian adult population, since they are more industrialized and economically developed than the non-capital municipalities. Our model had a moderate to good predictive accuracy. --- Conclusions In conclusion, our results indicate an increasing obesity epidemic in Brazil. The prevalences of overweight, obesity and obesity classes II and III increased in all sociodemographic subgroups between 2006 and 2019. However, speed and extent of weight gain varied by sex, age group, race/skin color and educational attainment. We observed a higher relative increase in the obesity epidemic among women, young adults, blacks and other minority ethnicities, and adults with 8-11 years of education. The projected prevalence of obesity may affect 3 out of 10 Brazilian adults by 2030; obesity classes II and III may affect 1 out of 10 adults. Our results also highlighted marked regional and sociodemographic inequalities in the obesity epidemic by 2030; approximately 24 out of the 27 geographic units may have more than a quarter of their population living with obesity; and prevalence of obesity classes II and III may be higher than 10% in eight out of the 27 geographic units. --- Data availability All data generated as part of this manuscript are included as additional files in this published article. Received: 22 March 2022; Accepted: 18 July 2022 --- --- Competing interests The authors declare no competing interests. --- Additional information ---

We examined time trends and projected obesity epidemic in Brazilian adults between 2006 and 2030 by sex, race/skin color, educational attainment, and state capitals. Self-reported body weight and height of 730,309 adults (≥ 18 years) from the Vigitel study were collected by telephone interview between 2006 and 2019. A multinomial logistic regression model was used to predict the prevalence of body mass index (BMI) categories as a function of time by 2030. The prevalence of obesity increased from 11.8% in 2006 to 20.3% in 2019. The projected prevalences by 2030 are estimated to be 68.1% for overweight, 29.6% for obesity, and 9.3% for obesity classes II and III. Women, black and other minority ethnicities, middle-aged adults, adults with ≤ 7 years of education, and in Northern and Midwestern capitals are estimated to have higher obesity prevalence by 2030. Our findings indicate a sustained increase in the obesity epidemic in all sociodemographic subgroups and across the country. Obesity may reach three out of 10 adults by 2030. Abbreviations BMI Body mass index CI Confidence interval NCD Non-communicable diseases WHO World Health Organization VIGITEL Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey Studies have documented the increasing obesity epidemic across the globe 1 . Between 1975 and 2016, the ageadjusted prevalence of obesity (i.e., defined as body mass index-BMI ≥ 30 kg/m 2 ) tripled worldwide, reaching 16% or 650 million adults in 2016 1 . The World Health Organization (WHO) Plan of Action for the Control of Noncommunicable Diseases aims to reduce by half the increase (slope) in the prevalence of obesity by 2025 2 . However, projections suggest this goal may not be achieved 3 . In Brazil, epidemiological studies have also shown an increase in the prevalence of obesity in adults from 12.5% in 2002 to 25.9% in 2019 4,5 . Overall, the prevalence of obesity has been higher in adults of lower socioeconomic levels and educational attainment 4,5 . Recently, a few studies conducted in high-income countries, such as the United States 6 and England 7 , have projected their national prevalence of obesity to inform local actions aimed to control the obesity epidemic 6,7 . In low-and middle-income countries, such as Brazil, projections of future obesity epidemic are scarce, despite its potential to inform public health policies and decision-makers. In Brazil, the Surveillance System for Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigitel) has conducted yearly since 2006 8 . Thereafter, over 50 thousand adults from 27 state capitals and the Federal District (hereinafter defined as geographic units) have annually reported their body weight, height, and demographic and socioeconomic characteristics, enabling the study of the current and future distribution of obesity in the Brazilian population over time 8 .

Although older adults have traditionally been conceived of as laggards when it comes to using the Internet , more recent research suggests that they may be catching up to younger age cohorts . This is an interesting development, since several studies have hinted at the potential of the Internet in helping them to adjust to day-to-day problems that can accompany aging ). Interviews with older adults participating in online communities, for example, showed that the community was an important resource for receiving feedback and comforting . Yet, research that has considered the elderly has tended to involve small-scale intervention studies or focused on older technologies such as e-mail or general personal computer and Internet use . Despite a growing amount of research in this area, we need to know more about the extent to which older adults derive benefits from the Internet. Research is particularly essential to better understand the use and implications of more recent technologies like social network sites . SNS use may be particularly beneficial for older individuals who may be in need of things this technology can readily offer , especially when they begin to experience daily-functioning problems, such as limited mobility, presbycusis, or other issues. In the present study, we used data from a large, longitudinal survey of older adults living in the Netherlands to examine two different pathways through which SNS use impacts subjective well-being and social loneliness. In the following sections, we first provide background information about social support among older adults and then evaluate two complementary explanations for the outcomes of older adults' SNS use . --- Social support, SNS use, and health outcomes among older adults Social support generally involves the connection between social relationships and well-being . Although it is a critical resource throughout the lifespan, there is reason to believe that older adults have unique support needs. Vaux argues that a person's needs, circumstances, and roles change throughout the lifespan. These changes may alter the form, amount, and network characteristics of support considered appropriate . Lack of adequate social support among older individuals has been linked to higher morbidity and mortality rates, increased depression, and a variety of other mental health problems . Two general explanations have been offered for the effects of social support on well-being. First, the direct-effects model asserts that simply being involved in social relationships can lead to physical and psychological benefits , even in the absence of a specific stressor. Ties between individuals influence human health positively if they satisfy the need to be socially and emotionally connected with others . Researchers have found that older adults benefit from the direct effects of companionship, which may lead to reduced stress, lower levels of morbidity and mortality, and improved psychological well-being . Yet, questions remain about whether online support can affect mental and physical health outcomes in similar ways. A second, potentially complementary, theoretical framework is the buffering model of social support, which posits that specific stressful events prompt individuals to seek out support . The buffering model suggests that social support serves to directly mitigate a stressor or one's appraisal of the stressor. For example, an older adult may receive advice to help solve a problem or feedback to change his or her perceptions of its severity. Researchers have linked the buffering model to positive health outcomes in terms of morbidity and mortality . In recent years, several studies have been published examining the implications of support from online sources among older adults. Pfeil and Zaphiris investigated an online support community for older adults and found that older individuals enjoyed building a sense of community in this setting where they exchange all levels of supportive communication. Kanayama reported that older people liked the additional time provided by online communication to construct and think about what they want to contribute. Other researchers have found positive associations between perceived support availability and older adults' use of the Internet to communicate with others and, more specifically, their friends and adult children . Although previous research suggests the potential of online support resources, adequate attention has not been given to the relationship between social support within SNS's and health outcomes for older adults. Yet, there is evidence to suggest the importance of SNS for support among other age groups. A survey conducted by researchers at the Pew Research Center showed that SNS users had significantly more support available than non-SNS users . Support perceived or available in SNSs has also been linked with well-being in several studies . In one study, the number of supportive interactions via SNS was positively associated with participants' positive affect . Despite not being conducted with older adults, these studies underscore the potential of SNSs as a support resource. The few studies on older individuals' SNS use that have been published so far provide some preliminary, supporting evidence. For example, social bonding was a major motivation for Facebook use among seniors in a study by Jung and Sundar . In addition, Hayes et al. found differences in how older and younger adults used Facebook and some indications that well-being outcomes of Facebook use may differ across generations. Finally, Bell et al. found that older adults mainly used Facebook to keep in touch with family, and suggested that social media may play a role in keeping older individuals who suffer from age-related problems connected in the near future. The direct-and buffering-effect models offer two pathways through which SNS use might impact the well-being of older adults. First, the direct-effect model suggests that SNS use might directly contribute to well-being. Through providing a sense of belonging or enhancing perceptions that one has a supportive network, SNS use should foster a more or less constant flow of small, well-being enhancing elements. The benefits of SNS use among older adults should be observed regardless of whether a stressor is present . We tested this idea by looking at the effect of time spent on SNSs on subjective well-being and social loneliness, controlled for prior scores on these variables, arguing that online social interactions should make older individuals feel better in terms of subjective well-being and reduce feelings of social loneliness or missing a wider social network . Hypothesis 1. Time spent on SNSs is associated with an increase in subjective well-being, and a decrease in social loneliness. The buffering-effect model offers a second, complementary pathway through which SNS use might impact the well-being of older adults. In accordance with the buffering-effect model, the benefits of SNS use on well-being should be especially visible in the presence of stressors or negative life events . In this project, we focused on functional disability, which refers to "limitations in performing independent living tasks […] necessary to function personally and in the community" . In other words, functional disability involves one's ability to accomplish every-day tasks in one's home and life. It is an important problem among older adults, which can lead to depression and reductions in perceived quality of life . Previous research has shown that time spent using online social networks is related to the amount of online problem-focused and socioemotional coping resources mobilized after a negative life event . We attempted to determine whether older individuals who are confronted with functional disabilities feel better off when they interact using SNSs, assuming that these interactions lead to social support exchanges or other types of coping assistance. In particular, we predicted that time spent on SNSs would moderate the impact of functional disability on changes in subjective well-being and social loneliness. The impact of functional disability on changes in subjective wellbeing and social loneliness should be buffered among older adults who use the Internet more frequently. Hypothesis 2. Time spent on SNSs moderates the relationship between functional disability and subjective well-being, and social loneliness. The effects of functional disability on subjective well-being and social loneliness will be smaller among older adults who spend more time using SNSs than among adults who spend less time on SNSs. The mechanisms through which Internet use may help protect well-being among older individuals are not necessarily merely social. For instance, participants in a study by Shapira et al. reported stronger sense of control and feelings of empowerment after they had learned to use the Internet. In addition, Slegers et al. found that older individuals agreed more strongly than younger individuals with the statement that computer and Internet use provided help in dealing with everyday problems. This should be especially relevant to those who are suffering from functional disability. If these older individuals can use the Internet to replace some of the offline activities they have difficulties with by online activities this may protect their well-being by giving them the feeling that they are still capable of managing their own affairs. Although we would not expect this to reduce feelings of loneliness, it does imply that practical Internet use may also decrease the negative impact of functional disability on subjective well-being. Hypothesis 3. Time spent on online shopping moderates the relationship between functional disability and subjective wellbeing. The effect of functional disability on subjective well-being will be smaller among older adults who spend more time on online shopping than among those who spend less time on online shopping. --- Method The Longitudinal Internet Studies for the Social Sciences is a large survey based on a true probability sample of the population of the Netherlands of 16 years of age and older. Data collection is coordinated by CentERdata at Tilburg University . Questionnaires are answered online. The survey includes non-Internet users, who were equipped with a computer and Internet access, and who received guidance in using them. This is important, because research has shown that even in the Netherlands, with one of the highest Internet adoption rates in the world, adding nonusers to an Internet panel improves the quality of the data . Surveys lasting 15e30 min are conducted monthly and respondents are paid 15 euros per hour to complete the questionnaires. Refreshment samples are drawn in order to deal with attrition. We used data from different modules collected during 2012e2014 . Our effective sample size e after listwise deletion and selection of respondents older than 55 years e was 2032 for the analyses of subjective well-being and 2162 for the analyses of social loneliness. We used this cut-off for age because functional disability is less common under 55. --- Variables Subjective well-being was measured with one item, which captures well-being as state1 : "How do you feel at the moment?". The answer categories ranged from very bad to very good . The measures we used came from questionnaires completed during November 2014 and May 2012. Social Loneliness is one of two components of loneliness captured by the De Jong Gierveld loneliness scale, and it reflects "missing a wider social network" . It was measured by three items: "there are enough people I can count on in case of a misfortune", "I know a lot of people that I can fully rely on", "there are enough people to whom I feel closely connected". Respondents were asked to choose from three possible responses: no, more or less, and yes. The items were reverse coded and the scale has good internal consistency . The timing of the loneliness model is somewhat different from the subjective well-being model. The loneliness items come from a different questionnaire, completed during February 2013 and February 2014. Functional disability was measured with a combined ADL and IADL scale . Respondents received the following question: "Below you will find a number of actions that some people have difficulties with. Can you indicate, for each activity, whether you can perform it without any trouble, with some trouble, with a lot of trouble, only with the help of others or not at all? This question does not apply to problems which you expect will not last longer than three months." Thirteen items were included: dressing; walking across the room; bathing/showering; eating, including cutting food; getting in/out of bed; using the toilet; reading a map; preparing a hot meal; shopping; making telephone calls; taking medicine; housekeeping/gardening; and taking care of financial affairs. We combined all items into one scale variable (by taking the mean; Cronbach's a ¼ 0.80) in order to enhance the sensitivity of the measure . All respondents completed this measure during November 2012. Table 1 shows descriptive statistics of the variables in our study. Respondents were asked whether they ever spent time on a list of Internet activities , and subsequently how many hours per week they usually spent on these activities. For the present analyses, we focus on time spent using SNSs and time spent on online shopping. All respondents completed this measure during February 2013. --- Analytical strategy A series of lagged regression models were constructed to evaluate the hypotheses. All models followed the same basic form. An initial model was tested containing functional disability, SNS use , and the lagged outcome variable as predictors. Respondents' sex was included as a control variable. A second model included the preceding variables along with the interaction between functional disability and SNS use . In other words, the regression equation we estimate in our full models can be represented as: Y t ¼ b 0 þ b 1 Y tÀ1 þ b 2 FD tÀ1 þ b 3 INT tÀ1 þ b 4 FD tÀ1 Â INT tÀ1 þ b 5 W tÀ1 þ e i where Y is subjective well-being or social loneliness, FD is functional disability, INT is time spent using SNSs or time spent on online shopping, and W is a dummy variable representing gender differences. The equation includes current Y as dependent variable and lagged Y as an independent variable. In models 1 and 3 of Table 3, and in model 1 of Table 4, we estimate this equation without the interaction term. Including the lagged outcome variable in the models made it possible to evaluate the degree to which the predictors were associated with changes in the outcome variable across the two measurement points. Separate models were tested for the two study outcomes: subjective wellbeing and social loneliness. If a direct effect of SNS use occurred, then the time spent using SNSs should be a significant predictor of changes in subjective wellbeing and social loneliness. If a buffering effect occurred, then there should be an interaction effect between functional disability and SNS use on both subjective well-being and social loneliness . The associations between functional disability and changes in the two outcome variables should be weaker among older adults who used SNSs more frequently and stronger among older adults who used SNSs less frequently. In other words, older individuals feel worse off when they experience daily-functioning problems but the use of social network sites may result in a less steep decline. --- Results --- Preliminary analyses Prior to testing the hypotheses, we first conducted some preliminary analyses to provide descriptive data about older adults' Internet and SNS use. Most older individuals used the Internet in the Netherlands in 2013. 88% of our sample of individuals older than 55 indicated that they sometimes used the Internet "besides when completing the questionnaires of [the] panel". Furthermore, our data showed that older individuals were still lagging behind considerably when it comes to adopting new Internet applications. Whereas the vast majority used email, only 26% used SNSs and 48% used the Internet to buy products . To put this into perspective: among those aged 16 to 25 86% used SNSs and 76% bought products online . There was a steep, downward age curve in the adoption of SNSs and online shopping. The chance that a person aged 56 to 65 used the Internet for these purposes was around three times larger than a person aged 76þ. In other words, the oldest individuals who used these applications are likely early adopters in their group. To get an idea of how quickly things change among older individuals we can compare these percentages to data one year later . By that time, SNS use had already gone up to 36% in the total sample and the share that used the Internet for shopping had gone up to 51% . As Table 2 shows, the age curves in time spent online are considerably less steep. The "youngest old" spent 2.43 h a week on SNSs on average, against 1.94 h a week among those older than 76. In the case of online shopping this was 0.86 versus 0.57 h. --- Testing the direct and buffering effects Hypotheses 1a and 1b predicted that time spent using SNSs would predict changes in older adults' subjective well-being and social loneliness. Models 1 and 3 tested these hypotheses and are reported in Table 3. As previously noted, all models controlled for an earlier measure of the dependent variable, as well as gender. As expected, functional disability was associated with worse mood . However, it was not a large effect, as it corresponded to a standardized effect of b ¼ À0.168. When controlled for functional disability and gender, SNS use had no effect on subjective well-being. The same was true for the effect of SNS use on loneliness . These results led us to reject Hypotheses 1a and 1b. Hypotheses 2a and 2b focused on the buffering effects of SNS use on subjective well-being and social loneliness. Time spent using SNSs was predicted to interact with functional disability for change in subjective well-being and social loneliness. Models 2 and 4 were used to tests these hypotheses, and the results have been reported in Table 3. We found support for Hypotheses 2a and 2b. The interaction effect was statistically significant for subjective wellbeing and social loneliness2 . Decomposing these interactions showed that the more time older individuals spent using SNSs, the smaller the negative effects of functional disability on well-being. How large is the buffering effect? One intuitive way to answer that would be to compare the functional disability effect of nonusers to the functional disability effect of those who spend an average amount of time on SNSs . With the interaction term in the model, the effect displayed for functional disability in model 2 is now the effect among those who spend 0 h at SNSs. For the average SNS user that effect is reduced to b ¼ À0.456 . In other words, the negative effect of functional disability on subjective well-being is 26% smaller for the average SNS user when compared with a nonuser. In the case of social loneliness, similar calculations show that the effect is reduced by 20%. Hypothesis 3 predicted that time spent on online shopping would also buffer the physical disability effect on subjective wellbeing. As illustrated in Table 4, time spent online shopping interacted with functional disability to predict changes in subjective well-being. Decomposing this interaction showed that the more time older individuals spent on online shopping, the smaller the functional disability effect on subjective well-being. These results supported Hypothesis 3. --- Robustness checks As a final step in our analyses we performed several robustness checks. A critical reader may wonder whether the interaction effects of SNS use and online shopping really result from those particular activities or instead from Internet use in general. In order to check this we performed two additional analyses. Both of these analyses supported the idea that the effects we found are really about SNS use and online shopping. First, we attempted to control for total time spent on Internet use. We created a new measure of time spent using the Internet for all activities, except SNS use or online shopping . Total time spent online did not alter well-being outcomes in these models and neither did it change the significance of the interaction effects on subjective well-being . The interaction effect of functional disability and SNS use on social loneliness became marginally significant when controlling for total Internet time and when using a two-tailed test . However, since our hypothesis includes the direction of the effect one could also argue that a one-tailed test is appropriate here. In that case the effect would still be significant according to conventional standards. Second, we checked whether an Internet-use variable without any theoretical meaning would show similar effects. We analyzed the effects of reading online news and magazines in place of SNS use or online shopping. As expected we found no interaction effects between online reading and functional disability on well-being outcomes . Taken together, these robustness checks offer evidence that the effects observed in this study are unique to SNS use and online shopping and not simply an artifact of total time spent online. --- Discussion The results of this study contribute to scholarship on older adults and the social implications of communication technologies by helping to better understand how and with what effects older individuals use SNSs. Drawing from the direct and buffering explanations for the benefits of social support, we considered the impact of SNS use as well as online shopping on older adults' changes in subjective well-being and social loneliness. Our analyses did not provide support for a direct effect of SNS use on well-being. This is in line with some of the studies among younger or general populations . However, the main conclusion of our study is that this type of Internet use can act as a buffer that protects well-being in older age. In addition, we conclude that the buffering effects of Internet use may not be restricted to social applications. Older adults who engaged in online shopping more frequently were less negatively impacted by greater levels of functional disability. These findings are in line with the idea that the Internet may play a role in coping with negative life events, such as health problems . In response to those problems individuals may turn to their online social networks and discuss their problems, ask for advice, or try to find someone who has experienced similar problems. When they receive social support with help of the Internet, it may reduce the impact of the problems they are facing. The opportunities that the Internet offers seem particularly important for those who suffer from reduced physical ability. Paradoxically, the ones that could profit most from online support are the least involved in the activities that generate the support. However, our results show that if older adults adopt these activities there are gains. There are at least two possible pathways to improved well-being. First, when individuals are no longer capable of getting out of the house without help, or when they are very restricted in their mobility, online interactions and support may relieve some of the stress that accompanies these problems. Second, there may be substitutions from offline to online activities. People's social lives are likely to suffer from reduced physical ability. Part of the missed social interactions can be compensated by interactions online. Similarly, some practical activities may be performed online instead of offline . In turn, this may mean that older individuals still feel more in control of their lives and capable of managing their own affairs and hence that they protect their wellbeing. This interpretation is consistent with qualitative studies in which participants reported feelings of empowerment after they had received Internet training . To be sure, we are not the first to examine buffering effects of Internet use. Mikal, Rice, Abeyta, and DeVilbiss provide overviews of how computer-mediated social support can help overcome the stress resulting from several "transitions". Moreover, studies that analyze the effects of online support groups on wellbeing are also about buffering effects in a certain sense, although they do not include individuals without problems and can therefore not estimate the effect of stressful events. However, to the best of our knowledge, we are the first to analyze the buffering effects of SNSs in a random sample of older individuals. The results underscore the potential importance of Internet use among this group. --- Limitations The effects we found for social loneliness were considerably weaker than for subjective well-being. This could be due to our research design. The change in loneliness we modeled did not come right after the measurement of functional disability but slightly later. It is plausible that the effect will be larger when changes are captured immediately. However, this limitation is somewhat offset by the benefit of having longitudinal data on relatively large group of older adults -a difficult population to sample, particularly over time. It also may be that the negative effect of functional disability on subjective well-being is simply larger than its positive effect on social loneliness. Mood changes rather quickly over time and is probably more sensitive to events than social loneliness. Future research should look at this more in depth. A second possible limitation is that the data we used came from a large, general survey. The advantage of that is that we were able to link Internet use to other relevant topics, like functional disability and well-being, and test our ideas using a large sample. However, the down side is that we have little in-depth information about what older individuals actually do online, who they meet, and what kinds of support they exchange or what they purchase. Future research should therefore complement our study by using different research designs , which provide more information about the mechanisms that cause buffering effects of Internet use.

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Introduction Internationally and nationally, violence against women has been recognized as one of the most serious forms of gender-based violations of human rights. Estimates from the Council of Europe suggest that between one fifth and one quarter of women across countries in Europe experience domestic violence at some point during their lifetime. Historically, violence against women has been conceived as a manifestation of the unequal power relations between men and women, which has led to discrimination against and oppression of women, and their subordination in relation to men. Women and girls are exposed to different forms of violence over their life course. This includes domestic violence, rape, sexual harassment, forced marriage, "honor" killings, and genital mutilation. Such violations of females have been recognized as a worldwide social and human rights problem that cuts across cultural, geographic, religious, social, and economic boundaries, affecting women in countries around the world, regardless of class, religion, disability, age, or sexual identity. According to the United Nations, violence against women and girls is defined as any act of gender based violence that results in, or is likely to result in, physical, sexual or mental harm or suffering to women, including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life. In the United Kingdom, the concept of domestic violence is informed by Women's Aid, a national charity working to end violence against women in the United Kingdom. With a network of 350 domestic and sexual violence services across the United Kingdom, Thiara, Hague, Bashall, Ellis, and Mullender defines domestic violence as physical, psychological, sexual and financial violence that takes place within an intimate or family-type relationship and forms a pattern of coercive and controlling behavior. This could include forced marriage and so-called "honor" crimes. Domestic violence often includes a range of abusive behaviors, not all of which are inherently violent. However, many authors have noted that dominant definitions of violence focus on the experiences of violence by non-disabled women but fail to represent those of disabled women, even though there is a plethora of evidence to suggest that disabled women and girls are more susceptible to systemic and individual violence across their life course compared with their able-bodied counterparts . Studies conducted in Europe, North America, and Australia have shown that over half of all disabled women have experienced physical abuse, compared with one third of non-disabled women . Nearly 80% of disabled women have been victims of psychological and physical violence and are at a greater risk of sexual abuse than non-disabled women . Balderston suggests that in the United Kingdom, disabled women are 2-5 times more likely than men and non-disabled women to experience sexual violence. Furthermore, several studies report that disabled children are approximately 3 times as likely to be sexually abused than non-disabled children . Accounting for gender, Sobsey, Randall, and Parrila found that significantly more disabled girls than disabled boys were likely to experience sexual abuse. This supports the work of Kelly, Regan, and Burton , which suggested that one in four disabled boys and one in two disabled girls experience some form of sexual abuse before their 18th birthday. This high proportion of disabled women exposed to and experiencing violence over their lives could be associated with a number of factors, including the fact that they are often perceived as dependent, asexual beings who cannot achieve the goals of womanhood-of engaging in healthy sexual or romantic relationships and of fulfilling traditional gender roles of wife and mother . Thiara et al. suggest that the perception that disabled females are not "proper" sexual beings or women could lead to them being at greater risk of sexual abuse. Furthermore, Cockram suggests that the fact some disabled women and girls have to depend on others for basic personal and social needs places them at greater risk of abuse compared with non-disabled women. This is evidenced by Barron , who cites the experience of a young disabled woman being offered assistance to the toilet by a male. She contends that although this could be interpreted as the woman being viewed as asexual, it could equally be seen as a way for a potential perpetrator to exploit the dependent nature of the relationship and be intimate with the disabled women who he, in fact, does view as a sexual being. The objectification of disabled women's bodies across their life course has also been suggested as creating opportunities for the abuse of disabled women. Work by Begum suggests that there is a tendency for society to reduce disabled women's bodies to asexual objects that can be controlled and manipulated by others. Belsky concurs, suggesting that contributing factors include the cultural devaluation of women and disabled people. Womendez and Schneiderman point out another significant factor as the lack of opportunities disabled women are given to learn the differences between appropriate and inappropriate sexual behavior. Other authors point out how disabled girls have had limited exposure to sexual knowledge and opportunities while growing up due to being excluded from the cultural spaces where these exchanges take place or being constrained by high levels of surveillance . This opens up ample opportunities for the abuse of disabled females within institutional practices as well as from different individuals with whom they interact over their lives. These include professionals, paid carers, family members, and intimate partners. For instance, Campling pointed out how her body was manipulated by health professionals when she was young: as the doctors poked and studied me endlessly I learnt more quickly than some nondisabled women that I'm seen as an object. . . . This is similarly evidenced by Thomas , who presents the narratives of disabled women with different experiences of gender and disability. One of the women recalled being routinely exposed to sexual abuse by a male doctor who knew she had no feeling in her lower body, in the name of "routine checkup," exemplifying the simultaneous oppression resulting from the interplay of disablism and sexism. Professional, social, and institutional practices, as discussed above, have often been taken for granted as a normal part of disabled people's everyday lives and not considered to be "abusive practices" in the same way that they would if experienced by a non-disabled child/adult. Work by Westcott and Cross and Shah and Priestley draw attention to practices of public stripping, disabled children parading naked in front of medical professionals and students who are strangers to them, and medical photography of disabled children and young people, experiences which would not be suffered by non-disabled children. These differing notions of acceptable and abusive behavior for disabled and non-disabled individuals is reflected in a quote by a social services team leader in a study by the British Association for the Study and Prevention of Child Abuse and Neglect : We accept that physical means of control are more acceptable for children with learning disabilities than for other children. Children are locked in their bedrooms at night. I know a child who is tied to a chair to keep him safe. We accept the differences but should we? Such attitudes by practitioners create barriers to knowledge, disclosure, and reporting in relation to the abuse of disabled children. Kennedy argues that there is a notion, among professionals, that abuse experienced by disabled children is of less significance than that experienced by non-disabled children. This in itself becomes a barrier to accessing support and protection. For instance, although disabled and nondisabled children are equally manipulated by the perpetrator to blame themselves, the former are less likely to be believed when disclosing the act . Even when signs of abuse, including sexual abuse, are recognized, practitioners seem to associate it with the child's impairment . Although disabled women and girls experience the same types of abuse as their non-disabled contemporaries, they are likely to be subjected to additional types of abuse specific to being disabled. The impairment-specific acts of abuse include those which simultaneously increase the powerfulness of the perpetrators and the powerlessness of the disabled women. Curry, Hassouneh-Phillips, and Johnston-Silverberg highlight experiences such as the misuse of medication, isolating individuals from family and friends, and removing the battery from the woman's power wheelchair as forms of abuse that non-disabled women/girls do not experience. However, as previously mentioned, these practices/actions may not be seen as abuse, either by professionals or by disabled people themselves. Even when disabled people do feel they are victimized, very few are in a position to report it to the authorities or a women's service such as Women's Aid. Several authors suggest a number of reasons for this, connected to the fact that disabled women and girls are likely to experience additional abuse by people on whom they are reliant, be they family members or paid carers, as well as intimate partners. Sobsey and Doe report how disabled women are likely to experience additional abuse at the hands of people who are supposed to "care" for them, such as personal assistants, parents, health care workers, and staff of residential settings . The dependent status of the disabled woman in such situations reinforces the notion that she is incompetent and powerless to resist or report perpetrators' advances, making her more likely to be victimized than a nondisabled woman . This is supported by Saxton et al. , who found that disabled women are less likely to get support or are prevented from accessing other sources of support when they are reliant on their abuser. At the same time, in cases where the perpetrator is also the disabled girl's/woman's assistant, they may be particularly reluctant to make a charge for fear they would be left with no one to provide the personal care they require to live independently . Apart from the barriers caused by perpetrators, much evidence suggests that disabled women face several obstacles when seeking professional support, which is open to non-disabled women . The obstacles include the lack of physical access to services, the inaccessibility of publicity materials, lack of accessible alternative accommodation such as refuges, and, as suggested above, social stereotypes that assume disabled women are asexual, tragic, or burdens to society. Furthermore, professionals' poor understanding of disability and impairment-specific abuse shapes responses to disabled women and frequently leaves them without protection from more general sources of support, such as the criminal justice system or other legal structures. For instance, disabled women may experience disbelief when approaching service providers about experiences of abuse in relation to their impairment or may even avoid accessing formal support for fear they would not be believed over the non-disabled perpetrator. Furthermore, where children are involved, disabled mothers experiencing violence may not seek professional help for fear they could be perceived as incompetent parents and experience interventions by legal and medical professionals in their reproductive lives . Bashall and Ellis note how policy makers and society in general do not conceive the impairment-specific acts of abuse as domestic violence or hate crime but more as "some innate vulnerability caused by their impairment" . This in itself is a major barrier to prevention and to accessing services and support. Therefore, despite the recognized large numbers of disabled women encountering violence, the obstacles they face, including the legal and protection frameworks that exist to protect women from violence, prevent them from getting the support they deserve to end the abuse in their lives. It is clear that continuation of violence of disabled women often stems from the inequalities associated with being disabled and female in a patriarchal society constructed around the non-disabled majority. The intersectionality of disablism and sexism helps to materially locate disabled women on the axis of power and disadvantage, and therefore provides a tool for understanding the complexity of disabled women's experiences of abuse and disadvantage. As Jennings pointed out, Women and girls with disabilities live at the intersection of gender and disability bias. Asa consequence, they experience higher rates of violence and lower rates of service provision than their non-disabled peers. However, the historic marginalization of disabled women, by disablism and patriarchy, means that regardless of the high rates of victimization experienced by disabled women , their experiences and voices remain absent from policy and research agendas, both in areas of domestic violence and disability. This "invisibility" from these two camps has contributed, in turn, to the high victimization of disabled women . Through the presentation of some preliminary qualitative evidence generated from the U.K. part of an European Commission -funded four-country comparative study, the aim of this article is to examine disabled women's experiences of violence and access to support over their life course. In this work, disabled women are identified according to the definition outlined by the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD; --- 2006): Women with disabilities include those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others. Through the first hand accounts of disabled women, this article will present examples of how women experienced different types of violence, including impairment specific violence. It will highlight the main barriers and enablers to accessing specialist and more general victim support services at different points in the life course. It will also bring forth disabled women's aspirations for the protection of survivors of violence and the prevention of violence against disabled women in the future. In so doing, it will provide the voices of a simultaneously oppressed group with the opportunity to enter the public domain and inform macro-level decisions that affect their lives. Before presenting these data, the article will briefly discuss the legal instruments, both international and U.K.-based, which currently exist in relation to violence against women in general and disabled women in particular. --- Law and Policy Acts of violence, once seen as a more private matter, have prompted the development of various international and national legal human rights instruments to protect women and girls from harm and abuse. With more than three million women affected by different acts of violence and abuse, the U.K. government has signed on to main international treaties related to violence against women and on the rights of disabled people. National legal instruments have also been developed in relation to violence against women and disabled people in the United Kingdom. However, a policy review conducted as part of the first phase of the EU research study mentioned above revealed noticeable gaps in existing legislation in relation to disabled women. This section will briefly discuss some of the international and national legal instruments relevant to violence against women in general and against disabled women in particular. It is by no means an exhaustive list. In 1989, the United Nations Convention on the Rights of the Child was the first international treaty proposed to protect the rights of children under Apart from law and policy with respect to women in general, there is also law and policy in relation to disabled people that seeks to protect the rights of disabled people, with articles specific to disabled women. The UNCRPD1 is the first international treaty to promote the civil rights of disabled people in all aspects of social life. Articles 6, 15, 16, and 17 are particularly relevant to this topic. In Article 6, the UNCRPD recognizes that disabled girls and women encounter multiple discrimination and propose measures to ensure they can enjoy their human rights. Article 15 proposes to take It may be noted, however, that charities are exempt from some of the requirements for building accessibility under Sections 193 and 194.2 This may include some charities that operate to support women who have experienced violence. Although the laws and policies highlighted here were not explicitly mentioned in the women's survival stories, in some instances they did contribute, albeit indirectly, to their escape and subsequent protection. --- Method The aforementioned EC-funded research project on which this article is based adopted a mixed-method approach to cover four phases of empirical fieldwork. These phases included an online survey of specialist violence support services across the United Kingdom, semi-structured interviews with key "experts" , four focus group discussions with a range of disabled women in different parts of the United Kingdom, and life story interviews with 15 disabled women. This article will report on preliminary data from the final phase of empirical fieldwork. It adopted a life story approach to generate data about the social world of a sample of disabled women across the United Kingdom who are survivors of violence and have experience of specialist support services. According to Atkinson , a life story is the story a person chooses to tell about the life he or she has lived, told as completely or as honestly as possible. What is remembered of it, and what the teller wants to know of it, usually as a result of a guided interview by another. The method of life history interviews to learn about experiences of disabled people, and especially disabled women, is still a relatively new approach . It is not only a personal narrative but also offers a unique understanding of development across time and space. As argued by Bertaux , when a life story is told, we not only hear the personal narrative but also become aware of the interplay between the individual and the broader social structures that gives substance to the narrative and contextualizes it within time and space. Furthermore, life stories offer a mechanism to learn about the experiences of oppressed or ignored groups not ordinarily included in official documentation. In so doing, it provides new understandings to existing knowledge on disability and on violence against women/girls, which can challenge assumptions and help to reexamine official documentation about the subject . It also allows a historically marginalized group to become agents of their knowing or knowledge creators. The life story approach also favors a social model lens and allows a space for nonmedicalized narratives to be voiced by disabled women, providing a space where participants can control when and how they communicate. It allows for the focus to move beyond the "life experiences of disabled people" and toward the "experiences of disability in people's lives," responding to Finkelstein's reminder that "disabled people are not the subject matter of social interpretation of disability" . Thus, the primary purpose is to reveal and challenge the network of social relations, institutions, and barriers that inhibit the full participation and equality of disabled women when trying to access support for abuse. --- Sample and Recruitment The target sample included 15 women with a range of impairments from different ethnic backgrounds and within the age range 18-65, stipulated in the original proposal for reasons relating to ethics and funding. All participants identified themselves as being survivors of violence and had experiences of accessing support at different points in their lives. The sample used for illustration in this article is drawn from six case studies, a subset from the larger study. The names have been altered using pseudonyms chosen by the participants. The characteristics of the subsample such as their age, ethnic origin, marital status, and impairment type are summarized in Table 1. All women became involved in the project through a process of self-selection. Disch asserts the importance of research participants being able to freely volunteer themselves for involvement in the research. Although this method would not produce a representative cross-section of the disabled female population, Booth and Booth maintain how such bias is permissible as it reduces the difficulties that could emerge from third-party explanations of the research. Furthermore, it confirms that the disabled women were in the right place in terms of their personal healing and confident about speaking out and sharing their realities. Table 1 Short recruitment notifications were published on the project website, on Facebook, and in newsletters of disabled people's organizations across the United Kingdom. A number of women responded to these. Other women learned about the work through their association with some of the expert service providers involved in the second and third empirical phases of the project. For example, five of the women attended monthly support groups for disabled women that were led by one of the experts interviewed for the second empirical phase. One disabled woman was on the board of trustees of another of the specialist services involved in the research. Another woman had just won a court case against her perpetrator with the specialist support of one of the experts . The final sample was made up of women based in different parts of England and Scotland. Once the women had expressed an interest in participating in the research, they were sent a Participant Information Sheet and Consent Form. Completion of the former provided some important information about the participant to ensure she met the sample criteria before interviews were arranged. It also provided space for participants' contact details so the researcher could keep them informed about the project as it developed. The women were also requested to provide alternative names for themselves, so their identities could be protected if they gave consent for their stories/experiences to be disseminated in publications and reports. The Consent Form allowed them to give written consent. However, written consent was normally acquired after the interview had taken place and the researcher had verbally explained the aims and objectives of the research, and how the women's stories would be used. Higgins and Swain propose that the process of explanation is important as it influences the acquisition of informed consent. The researcher tried to be as open and honest as possible in her explanation of the research and allowed the women to hold the reins to the interview process. Although the researcher guided the women through the interview with a very open topic guide, ultimately the women had control over how and if they responded to these questions. Furthermore, they determined whether they wanted a break and when to resume the conversation. This was especially important given the sensitive nature of the topic. Use of Empathy Most of the interviews were conducted by the first author of this article, who herself is a disabled woman. It can be argued that her ontological position, as a disabled female researcher, was key to the development of this research. Leicester and Oakley suggest that interviewing individuals with similar experiences encourages the generation of richer material. Stanley and Wise describe this experience of knowing as an "epistemological privilege" , with researchers having access to a priori knowledge of their informants' subjective realties by virtue of their shared experiences. The researcher and the researched shared the identity of being disabled women and the experiences of simultaneous oppression it engenders. This was helpful in terms of recruiting participants, building rapport with them, and encouraging them to be more open. Nosek et al. concur with this, suggesting that a non-disabled interviewer may create a psychological divide when interviewing a disabled woman. However, they also point out that although a disabled interviewer may establish rapport with disabled participants more rapidly, their shared experiences could cause them to digress from the interview agenda. During her PhD training, the disabled researcher had been made aware of the dangers of "overrapport" and, taking Moser's advice, adopted a "pleasantness and a business-like nature" . Furthermore, the researcher did not have any experience of abuse herself and thus was able to retain a fair level of objectivity when interviewing the women. Bondi contends that some level of objectivity is important as it enables the interviewer to be emotionally present and reactive to the interviewees' responses while staying in touch with and reflecting on their own feelings. In this way, there is not a danger of the interviewer becoming unconsciously overwhelmed by the respondents' stories, reacting to, rather than reflecting on, what is going on, and blurring the interviewer/interviewee boundary . The Interview Once the women had responded to the recruitment request and completed the Participant Information Sheet, arrangements were made between themselves and the researcher for the interview. The women were presented with options as to what format of interview would be most accessible for them-face-to-face, via email, via Skype, telephone. All women expressed a preference for face-to-face interviews. The location of the interviews was chosen by the disabled women. Most of them expressed a preference to hold interviews in their own home, which was considered safe and accessible for them. In cases where women felt this was not appropriate, they were interviewed in a women's support service that was local and familiar to them. Arrangements for this were made through negotiations between the researcher and the relevant expert service providers. Service providers also offered to provide support to the women, if they required it, as a consequence of being re-traumatized by the interview. Only one of the interviews was conducted in a public place as it was convenient for the participant. The possible problems of discussing such a private and sensitive topic in a public place were noted, but the participant was not concerned. During the event, no problems were encountered. The only problem related to the transcription of the interview, which was occasionally difficult due to background noise. All interviews were between 60-120 min in duration. However, breaks were incorporated into the interview time for different reasons, including because the participant requested some time to regain her emotional composure after recollecting traumatic experiences, because they needed a comfort break, or because they were needed to provide assistance to someone else. For instance, one of the women described herself as a full-time carer to her 80-year-old mother who had Alzheimer's and thus needed to interrupt the interview when her mother needed personal assistance. --- Research Findings Drawing on the data from the six selected case studies, this section of the article will present the disabled women's reflections on the different types of violence they encountered at different points in their lives including impairment-specific violence, their experiences of the formal and informal support mechanisms they drew upon at these times, and their own aspirations for the protection of disabled women/girls who have survived violence and the prevention of such violence in the future. In this regard, three key themes will be discussed here: "Experiences of violence over life," "Access to support," and "Future aspirations" to exemplify the reality for disabled women who are survivors of violence. Theme 1: Experiences of violence over life. According to the disabled women in the sample, the situation of violence encompassed several things, including physical and sexual violence, emotional abuse, or economic coercion. Physical violence was seen in terms of being hit and beaten, and psychological or emotional violence involved being verbally attacked, physically isolated from others, and being conditioned to feel worthless by the perpetrator saying and doing things to purposely lower the woman's selfesteem and confidence. Women gave examples of the types of violence they encountered at different points in their life course, from childhood to adulthood. For example, Barb recalls being violated at different stages of her life, from the age of about 8: I think at different stages through my life there's been things that have happened. Sort of as a child I remember being, I suppose you could call sexual assaults, when I was about eight years old. Then in my marriage, I was married at 17, my husband was physically violent to me maybe about 4 times. And then the longer relationship that I had later on was everything: physical violence, sexual violence, emotionally and I tend to see a sort of mental torture that's quite different, it's a sort of extreme of the emotional abuse. It was really, really bad, to the point where it was absolute mental torture. Samantha reflects on the violence she was subjected to over her life by different male perpetrators, starting in childhood by her brothers, who beat her. At the age of 19/20, she was forced, by her brothers, to marry a much older man who also abused her: in those days we couldn't say nothing to our parents. My mum died when I was two and my dad died when I was 16. My brothers used to beat us up a lot; maybe because they wanted to be-yes, in other words that's right-they wanted to be in control. They were controlling us, they were controlling all the sisters. All my three brothers . . . They arranged or forced my marriage because my dad had passed away when I was 16. I was 20 at the time and he was about 40; or he could have been 60. You know he never told me his age! And for the sake of me starting to talk to my sisters and my brothers I got married but I stayed in India for ages; eight months. They wouldn't let me-my husband wouldn't let me come back to England. I tried to commit suicide a couple of times and they [the husband's family] just got fed up and sent me back to England. Lois also recalls experiencing abuse by a male member of her family. Her experience was longitudinal, starting during childhood and ending in early adulthood. Like Sam, she tried to eliminate the memories of the violence and the psychological scars it caused. However, she did this through alcohol as opposed to attempted suicide: when I was about 6-7 and 13 I experience abuse from an extended family member . . . when I was about 14 or 15, I was raped, but maybe one or two friends knew about that but no one really knew it didn't come out in full until I was 18 or 19. . . . I used to have to drink a pint glass of wine before I go to sleep and that was usually in combination with a lot of my medication as well, so that would be how I would get to sleep without worrying. I used to not being able to handle being in any sort of silence and cope with it because of my mind would take over and get trapped and think really negative. Some of the women experienced impairment-specific abuse, a type of violence not experienced by non-disabled women. This type of abuse took place out of sight. It was related to isolation, control, and manipulation. For example, Adele recollects how she experienced abuse for a good part of a decade, starting when she was a young teenager. The perpetrator, who was in his 20s at the time, was Adele's carer and sexual partner. Adele believes that the perpetrator definitely took advantage of the fact that she had an impairment to abuse her. However, at the time she did not recognize it as abuse: He would tell friends that I was poorly when he'd zonked me out. If you've had very strong painkillers, you're very dozey; so he would purposefully give me the strongestpainkillers when my friends were coming, and they couldn't come then obviously because I was asleep. He would cancel care shifts, he would then say that I'd cancelled them, because again when you've had them tablets you're not good at remembering anything-even what your name is . . . he'd give you so much that you didn't know what you'd done . . . I just woke up and I thought I might have smacked myself in the eye. Now luckily I'm not with him anymore. But, like now, my mates know if I've smacked myself in the eye. Before now, I didn't really know what he did to me which is probably the worst thing actually. Alison, another participant, was victim of physical, psychological, and financial abuse. She identified some of the violence she experienced by her three husbands as related to her being disabled. She believes all of them saw her as an easy target and easy to control: My first husband saw me as a meal ticket because of my impairment. . . . My husband, at the time, isolated me from my peers so I felt so alone. . . . It was about control; if you're abusive it doesn't matter where the abuse leads it's always about control. They've got a manual, they've got the same book; you can laugh but they have. Theme 2: Access to support. The women mentioned different kinds of support they tried to access at different times. This was both formal and informal, resulting in positive and negative outcomes. There were several examples of women experiencing barriers to accessing support over their lives. These barriers were caused by different individuals and structures. For instance, both Barb and Lois remembered how their own families avoided formally reporting the abuse they experienced for fear of the scandal it may create: I think the thing that hurts me the most was probably my parents' reaction-my mum particularly, I think they must have been thinking do they phone the police, if they do, you know, it'd be a big scandal; it would be in the paper-all this kind of thing. A sort of shameful situation and I remember hearing my mum saying that "she's young, she'll just forget about it if we don't mention it." And it was just swept under the carpet. Lois was sexually abused by her cousin from when she was age 7-13. Although it was made known to her immediate and extended family, her family was frightened of the scandal it may cause within their community and thus preferred not to formally report it to the police at the time. When Lois was 18 and went to the police herself, she felt she was not fully believed because her parents "were in denial" and thus "skipped over what was important" in the reports they gave. Alison tried various avenues of formal support for the domestic abuse she was subjected to by her husbands. However, she faced disabling attitudinal barriers by different support services, including social services, women's support services, and the court. Instead of supporting her to escape her abusive partner, the support services removed her children from her for awhile. Understandably, this made her very cautious when accessing support: I did try but they just didn't grasp it . . . and when I did turn to anyone for help it went all wrong so in the end I nearly lost the kids, I did lose the kids for at least a while . . . Me: I was branded as the worst mum in the world. Despite the fact Alison was experiencing ongoing violence from partners, she could not access formal or informal support. She requested to be relocated for her own and her children's safety, but there were no services that offered support for her as both a disabled woman and mother: I should have had the support from the services but it wasn't there-not for me. Other families with non-disabled mums in similar situations, had been lifted in the middle of the night, put into taxis and relocated where they could; to another part of the country so that the man could not get at them . . . there was only a provision for either me as a disabled person or for the kids; there wasn't provision for a disabled woman that had kids. Barb also had to put up with years of severe abuse from her second husband. This started in 1988: I don't know how I got into this situation but it turned out to be 16 years long and it was just very, very bad; violence, sexually violence; rape, hundreds of times literally. Just completely broke me down and I just think that people understand that there's abuse and there's just absolute torture in it's extreme form and that's where the relationship went. Barb's husband had isolated her from her family and friends for years, since the late 1980s. She became so frightened that she never told anyone of the violence she experienced. She believed there was no way out. However, she was hospitalized a number of times, as a consequence of her injuries, and thus medical services and the police were aware of the high level of domestic abuse she was being subjected to. At the time, standard practice was for them to wait until she cried for help. They did not seem to understand that years of abuse and intrinsic fear for herself and her children meant she lacked the confidence to make a formal complaint. This unfortunately meant the police were not prepared to charge the perpetrator, and he was free to continue to victimize. Barb again and again: . . . I don't think I told anyone but lots of people knew because there was a lot of police involvement and things . . . he made sure I was isolated from family and friends when there were opportunities to get help like from the police or from my doctor I was quite seriously injured a number of times and hospitalised a number of times . . . I think in some ways that the attitude of the police could also be a huge problem because in some ways I felt that they looked on me as being just as bad because I wouldn't do something about it; you know sort of "how do you expect us to help you if you won't help yourself?" Yes, that's fine but I couldn't help myself. I don't think they were able to sort of understand this prisoner of war camp that I had going on. You know I remember at the very end when I was finally leaving the police put it too me that "you know we've tried to help you so many times." At this point I was actually going, I'd left the house and I was asking them to help me and the inspector was like "Why should I put my officers at risk so you can go home and play happy families tomorrow?" . . . Lois also wanted assistance from the police but felt her drinking and sexually promiscuous behavior, adopted as mechanisms over the years to cope with the scars of abuse, would be used as negative evidence and reduce the likelihood they would help her: I felt I couldn't go to the police because I felt I'd be scrutinized and I felt that everything that I'd done ever since would be used as evidence against me and because I felt all is based on your character and instead of being believed and because of the way I behaved in the time since what has happened to me, I felt like people would say it's my fault or I brought it on myself or that I have to go to court and explain things . . . I thought it would be very easy for anyone to say well of course with how much you have drunk at the time. . . In Barb's case, however, eventually the police did take positive action and persuaded her to leave the abusive situation: by 2004 the police weren't just going to go away, they were coming in. And you know the police then did press charges against him, regardless of what I said, based on what they could see. So I think whether there'd been changes in legislation during that time or the approach that the police would take; the sort of guidelines that they worked within. This could have been prompted by several things, including the approach taken by successive U.K. governments to tackle domestic violence by policy development , and Barb's own agency and self-confidence to negotiate her own escape routes. She believes that becoming employed in a support service for people with her impairment provided her with opportunities to learn about similar cases and support mechanisms, both specialist and more mainstream support services like Women's Aid. She also befriended someone from work in whom she confided: In January my friend and her husband drove me to my kids' school and picked them up and we ran. My three youngest children we got from school and we went into refuge with Women's Aid. And that was the last time we ever went back there. In another case, Shirley reveals how she was continuously physically abused by her father when she was growing up in New York City in the 1970s. She believed that part of the problem was children did not have many rights as they do today. This was prior to the Children's Act and when child abuse was a private affair, not a public matter: When I was 14, I called something called Child Protection Services, in New York City in America and I was told I would be entitled to Family Counselling. I said that I thought my father was a danger to me and that he was excessively violent, and that I was in fear of something horrible happening to me like him putting me in hospital. And I was still pretty much fobbed off, and it was the family counsellor who said that until he did something quite nasty that would put me in hospital they could not do anything. Even where her scars were obvious, professionals failed to believe Shirley was being abused and thought she was the cause: they thought I was a heroin addict 'cause I was so thin and I had needle scratches because I was having medication and I was also having convulsions and with the convulsions they made assumptions and thought that I was a heroin addict and they treated me like a piece of dirt . . . I collapsed on the floor and I was there for an hour and I then crawled back to my room and then I lost consciousness and was in a coma and they had to give me an adrenalin shot and I still have the scar. On a more positive note, both Adele and Samantha discovered a support service in their home city that specialized in providing support to disabled women. It was run by a disabled woman, herself a survivor of domestic violence. The two women believed that joining the service and meeting other disabled women with similar experiences was a turning point for both of them. It provided them with a means to regain their confidence enough to be able to stop what was happening to them. For instance, after being in an abusive relationship for 10 years, Adele decided it was time to get out. She speaks of how meeting the manager of the disabled women's support service prompted her to do so: I was 23 when I started trying to get out of it but it takes a lot of time. I think to get to the point where you can't stand it anymore. You try to change it but then it doesn't change and you have to get out . . . she was talking about smear tests and stuff like that. Then afterwards she started talking about this: domestic violence towards women, and it just sort of clicked into place that I've got to go, he's got to go. Even if I had to go back to my parents he's got to go. Theme 3: Future aspirations. At the end of each life history interview, the women were asked, "If you had a magic wand what would you wish for to protect disabled women and girls from violence?" Several of the women emphasized the importance of education and training to promote an awareness of the consequences of violence for both the abused and the abuser. Also there was a perception that through disability awareness, members of society could learn acceptable and unacceptable treatment for disabled people, and how it should not be different to what is acceptable and unacceptable for non-disabled people/children. Alison suggested that disabled girls should be given sex education in schools, be this segregated or mainstream. It should include knowledge about the differences between right and wrong sexual behavior, information about their entitlement to resist anything they do not like no matter who the perpetrator is, and advice about how to report any wrong behavior. The last word is from Barb, again in relation to education and ensuring women can access the right information: I know that nowadays the health visitor will talk to new mums about postnatal depression. Well maybe the subject of violence in a relationship could be covered at that stage; just really getting the information to women. If it hadn't been for my work I wouldn't have known that there were people out there that could help and when it came to it for me the obvious people like the police didn't give me that help initially; I had to do it for myself. Yes, educating people and getting the information to people would help. --- Conclusion This article brings the voices of disabled women to the forefront of debates on violence against women and on disability, two areas of research and policy that have marginalized the experiences of disabled women. It discusses the reality that disabled women are significantly more likely to experience violence compared with their nondisabled contemporaries, at the hands of different perpetrators, including paid and unpaid carers, and in various ways, including those specific to their impairment. Drawing on preliminary evidence from life history interviews with disabled women based in the United Kingdom, the article suggests how disabled women and girls experience particular types of violence specific to their impairment, which is often not recognized as violence , but rather is seen as part of the everyday life of a disabled person. Furthermore, the article highlights how disabled women are at the intersection of gender and disability bias and, as a result, are likely to encounter a range of barriers to support. Such barriers are influenced by a number of factors, including historical perceptions of disabled women as asexual and incompetent as sexual partners or mothers, being dependent on perpetrators for personal care, physical inaccessibility of specialist victim support systems, and the disbelief women face when reporting their experiences to professionals. However, regardless of these barriers, the disabled women introduced in this article are all survivors because they drew on other support mechanisms, including their own agency, and support from, and identification with, other disabled women. The article explored concepts of empathy and identification, highlighting how personal ontological research resources have not only become recognized as valid sources of scholarly knowledge, but also a means to enable respondents to share experiences with an empathic other . As Karl observes, a sense of empowerment comes from being respected and recognized as equal citizens with a contribution to make. Facilitating disabled women to speak out for themselves about their experiences of violence and support over the life course can inform the development of specialist outreach programs within mainstream women's support services such as Women's Aid and Rape Crisis and also within disability organizations, often criticized for dismissing the issue of violence as not being part of their mission . Violence-related stories from disabled women can also be drawn on to design policy and training materials for statutory services and different parts of criminal justice systems. In this regard, therefore, learning from insider perspectives is crucial to develop tailored mechanisms to reduce the prevalence of violence against disabled women and girls in the future.

Violence against women is a worldwide social and human rights problem that cuts across cultural, geographic, religious, social, and economic boundaries. It affects women in countries around the world, regardless of class, religion, disability, age, or sexual identity. International evidence shows that approximately three in five women experienced physical and/or sexual violence by an intimate partner. However, across the globe, women and girls with impairments or life-limiting illnesses are more susceptible to different forms of violence across a range of environments and by different perpetrators including professionals and family members as well as partners. However, they are likely to be seriously disadvantaged in gaining information and support to escape the abusive relationships. This article stems from the United Kingdom part of a comparative study with three other countries (Austria, Germany, and Iceland) funded by the European Commission (EC; 2013-2015). It presents preliminary findings, generated from life history interviews, about disabled women's experiences of violence and access to support (both formal and informal) over their life course and their aspirations for the prevention of violence in the future. The article includes examples of impairment-specific violence that non-disabled women do not experience. By bringing the voices of disabled women into the public domain, the article will facilitate a historically marginalized group to contribute to the debate about disability, violence, and support.

Background There has been increasing recognition in Slovenia of the societal implications of intimate partner violence , defined as "behaviour within an intimate relationship that causes physical, sexual or psychological harm, including acts of physical aggression, sexual coercion, psychological abuse and controlling behaviours" [1]. The reported prevalence in Slovenia [2][3][4], as well as a growing body of research on health consequences related to IPV [5][6][7][8][9][10][11] and its impact on morbidity and mortality [5], all suggest a gradual change from IPV being seen as a personal and family issue related to the legal and justice system, to an issue that needs to be acknowledged and addressed as a public health problem. Women have traditionally been considered the victims and men the perpetrators of IPV [12,13]; this is probably due to findings that men use more physical force and sexual coercion and are more likely to cause injuries [14][15][16][17][18]. However, women were reported to be more likely to employ psychological aggression [19]. In a limited body of research, it has been suggested that female perpetrators are more likely to suffer from mental health difficulties, especially anxiety and depression [20,21]. Although knowledge of the comparative health effects of different types of IPV is limited, some studies have indicated that victims' exposure to psychological aggression may be more strongly associated with the onset of depression, anxiety, somatisation, and post-traumatic stress disorder than other types of IPV [9,14,20,[22][23][24]. Coker et al. [14] reported both physical and psychological IPV to be associated with significant physical and mental health consequences in victims regardless of gender. Women were significantly more likely than men to experience and report physical or sexual IPV and abuse of power and control, but less likely than men to report verbal abuse alone. For both men and women, being a victim of physical IPV was associated with increased risk of current poor health. In general, abuse of power and control was found to be more strongly associated with adverse health consequences than verbal abuse, and psychological violence was shown to be more damaging to overall health status than physical abuse [14]. In another study, Coker et al. [25] explored the consequences of IPV on physical health and found that women experiencing psychological IPV were significantly more likely to report poor physical and mental health. Psychological IPV was as strongly associated with the majority of adverse health outcomes as physical IPV [25]. Summarising the findings of existing studies, the adverse effects of IPV on women's health should be noted, such as chronic pain [5,14,26], chronic stressrelated symptoms [27] and central nervous system problems [5,14]. Authors worldwide mostly agree in their findings on both the short and long term physical and mental health consequences of IPV exposure [5,28,29]. IPV exposure has been found to be associated with an increase in psychoactive substance use, anxiety, depression, suicidality, and post-traumatic stress disorder symptoms [14,[30][31][32][33][34][35][36]. Undoubtedly both men's and women's IPV exposure should be explored in IPV research, but the findings need to be interpreted with caution. Psychological abuse has been shown to be the most frequent characteristic of interpersonal violence dynamics, affecting women's health as severely and significantly as other types of abuse [25,26]. However, the frequent co-occurrence of psychological aggression with physical violence, as well as difficulties in measurement, combine to reduce certainty with regard to the independent effects of psychological aggression on health. Some recent research showed that more men than women reported exposure to physical assault, while more women reported exposure to sexual coercion in the past year [37]. However, it should be mentioned that studies which found similar levels of IPV in women and men relied largely on past-year estimates or current partners, whereas studies assessing a longer time-frame or including previous partners tended to find dissimilar levels of violence [38]. The risk factors for IPV exposure in a cross-sectional population-based study in Sweden were the present relationship being of at least three years duration for men's exposure, while a young age, lack of social support and being single constituted risk factors for women's IPV exposure [37]. Compared with women who had never been abused, those reporting only psychological abuse were more likely to present negative mental health indicators in a study carried out in Spain [39]. Despite the abundant literature on the consequences of IPV on health, psychological abuse has rarely been considered a relevant health-related problem and has never been studied as such in Slovenia. After reevaluating the prevalence data for past IPV abuse and showing an IPV exposure prevalence of approximately 17% as a valid estimate [4], it was decided to focus on the separate effects of psychological IPV on family medicine clinic attendees. This study aims to explore the differences between patients who were exposed to psychological IPV in the previous year and those who were not; to identify the health consequences and other patient characteristics associated with this type of IPV exposure; and to examine whether there were any specifically gender-related issues in family clinic attendees. --- Methods --- Participants and procedure In January 2013, 90 general practitioners , i.e. family physicians who have finished four years of specialised training, who had already taken part in the 2012 IPV prevalence re-evaluation study [4], were invited to participate in this study. Sixty-four of them responded affirmatively . They were provided with written instructions on the approach to the patients and data collection, i.e. the semi-structured interview forms and the medical charts review forms. --- The first phase: recruitment of patients The first phase of data collection was carried out during the first week of March 2013, when the participating GPs, working in family practices all over the country, asked every fifth family practice attendee aged 18 years and above, regardless of gender, to participate in a study on quality of life. The eligibility criteria for this phase were age, the absence of dementia or even mild cognitive impairment, and the patients' willingness to participate. The aim of the study was not explained, but the subjects were told that participation was not obligatory. Those willing to participate were scheduled for interview within two weeks. This phase of data collection ended either after 15 patients had been recruited, or on March 8, 2013, whichever was the earliest. --- The second phase: interviewing the patients Of 960 invited patients, 689 interviewees came to family practices during the second phase, which lasted until the end of March. Since research has shown that disclosure of IPV violence is highly influenced by interviewer factors as well as privacy and the context of the interview [40], participating GPs were encouraged to revise the semi-structured interview form prior to interviewing patients, and to contact the coordinating researcher if in need of assistance or consultation. At the beginning of the interview, the participants were told that exposure to IPV could be considered a serious quality of life issue in adults. After the topic was introduced, they were asked to sign a written consent form. Of the 689 patients, 45 decided against further participation; they were not asked to explain this decision. In total, 644 interviews were carried out and 609 patients declared they had had an intimate partner during the last five years. Those who had not been in an intimate relationship in the previous five year period were excluded from further analysis. A further 109 patients disclosed they had experienced specific acts of psychological abuse earlier in life but not during the past year, and another 30 people stated that they had been exposed to concurrent psychological and physical and/or sexual abuse. The latter group explained that aside from psychological abuse they endured behaviours such as hitting, slapping, kicking, pushing and/or being forced to engage in sexual activities against their will. As the study aimed to analyse solely psychological abuse in patients, those who had experienced psychological IPV during their lifetime but not in the past year were excluded from the analysis. Victims of multiple types of abuse were also excluded from the study, but were offered help and assistance. The drop-out data are presented in Figure 1. --- The third phase: auditing patients' medical charts After interviewing the patients, GPs reviewed their medical charts in the third phase of data collection. The Domestic Violence Exposure Medical Chart Check List from the 2009 study, described in detail elsewhere [2], was used for this purpose. --- Participants: study sample The final sample consisted of 470 patients, who had been living in an intimate relationship during the past five years, and who had not had previous psychological abuse, or concurrent physical or sexual IPV exposure. The National Medical Ethics Committee of the Republic of Slovenia approved the protocol of the study . --- Measures The semi-structured interview form consisted of several questions from the short form of A Domestic Violence Exposure Questionnaire, described by Kopcavar-Gucek et al. [3] and developed in previous studies in Slovenian primary care [2,41]. The questions gathered data on gender, age, number of children, marital status, number of divorces and place of residence. To identify psychological IPV adequately, more specific questions with comprehensive, behaviourally-defined descriptions of interpersonal violence events in closed questions were used in the semi-structured interview. The behavioural patterns of exposure to psychological violence were also inspired by the work of other authors [39,42]. This also aimed to avoid subjective understanding of the criteria of psychological violence in victims. For better orientation in time the national holiday March 8, International Women's Day, was used; this timeframe was introduced to patients with questions like: What does March 8 mean to you personally? Do you acknowledge this holiday? What did you do this year? Are you able to recall the March 8 of last year? The patients were told that the subsequent questions were to be considered within this timeframe and were then asked a series of questions: Do you feel safe at home? Do you feel accepted, respected and loved in your intimate relationship? Have you been humiliated, subjected to threats, insult or intimidation, or in any way emotionally affected by your intimate partner? Does your partner talk down to you? Has he/she demeaned or insulted you or made you feel ashamed? Has he/she screamed or cursed at you? Has he/she threatened you with physical harm? If such a thing has happened, have you been thinking about doing something about it? Do you want me to help? Patients were asked to specify whether this had happened in the 12 months preceding the survey, i.e. between March 8, 2012 and March 8, 2013. These questions had several possible responses . Participants were considered to have experienced "current psychological abuse" if they answered any question many times or sometimes. Others who answered to each question negatively were marked as negative for current abuse. The second part of the survey, replicating the procedure of the 2009 study [2], was carried out by the GPs themselves after the interviews. Further information on the participating patients was gathered by auditing medical charts, including data on the patients' wider life context. The physicians analyzed the patients' medical charts and abstracted factors at both the personal level and at a relationship level [i.e. past experience of violence reported by patient and marked in the medical chart; disputes in the intimate partner relationship , reported by patient and noted by the physician; and dysfunctional family relationships , already discussed with the patient and marked by the physician], from the whole medical chart. Health-related associations with exposure to IPV were also listed and audited for the previous year , and were later categorized into three groups: physical, sexual and reproductive, and psychological. Lastly, sick leave , hospitalisation , visits to family clinic and referrals to other clinical specialists in the past year were reviewed, noted and analysed. 'Frequent' among participating patients was defined as within the top 10 centiles in a time frame of one year for each characteristic . --- Data analysis The sample data were presented as frequencies and percentages. Bivariate comparisons were made using the χ 2 test or Fisher's exact test. The analysis compared patients who reported having experienced any act of psychological violence in the past year with those who did not report any IPV . Demographic characteristics, the data obtained from patient medical charts for the time prior to the psychological IPV screening period, and current health status variables were included in the modelling process, but not these without significant bivariate associations with past year psychological IPV exposure . Multivariate logistic regression was used to model those factors associated with past year psychological IPV exposure in the total sample and separately for women only . With the aim of avoiding conceptual overlapping between the independent variable disputes in intimate relationship and the dependent variable, another regression modelling was performed without this independent variable, which had been earlier identified as a powerful risk factor for psychological IPV exposure. Similarly, an additional regression modelling was made for female patients without the independent variable disputes in intimate relationship. The results were presented by crude and adjusted odds ratios with 95% confidence intervals. Statistical analysis was performed by IBM SPSS 20.0 software , and P < 0.05 was set as the level of statistical significance. --- Results Of the sample, 12.1% people had been exposed to psychological IPV in the previous year . --- Demographic characteristics of patients The average age of all participants was 47.4 ± 16.1 years; the average age of men was 48.2 ± 15.8 years and of women 46.9 ± 16.4 years . The average age of patients without experience of psychological IPV was 47.4 ± 16.2 years; men 48.6 ± 15.6 years and women 46.5 ± 16.6 . People who had been exposed to psychological abuse were 47.8 ± 15.6 years old; of them the men were 42.7 ± 17.7 and the women 49.0 ± 15.1 years old, the latter being seemingly but not significantly older . More demographic characteristics of the sample are presented in Table 2. --- Frequent use of health care services during the past year among participating patients There were no statistically significant differences found between people exposed to psychological IPV and those who did not report such experiences . --- Patients' medical charts review summary In Table 3, the summary of patients' medical charts is presented. Statistically significant differences were identified between the patients exposed and those not exposed to psychological IPV, with regard to muscle inflammations , sexual and reproductive status in general , specifically gynaecological disorders and inflammations , complicated pregnancies/spontaneous abortions , psychological and behavioural status in general , including the onset of depression and/or generalised anxiety disorder , eating and sleeping disorders , low self-esteem , phobias and panic attacks , post-traumatic stress disorder and psychosomatic disorders , all assessed or diagnosed by practising GPs in the year prior to the survey. --- Associations between psychological intimate partner violence exposure and bio-psycho-social characteristics in patients: logistic regression modelling In the regression modelling process, the associations between psychological IPV and the characteristics of patients were explored. Employment status , level of education, i.e. college degree or more , the length of intimate relationship ≥ 6 years and a history of disputes in the intimate relationship already noted in the patient's medical chart were identified as risk factors, explaining 41% of the variance . More results are presented in Table 4. In another regression modelling performed without independent variable disputes in intimate relationship, 27% of the variance was explained , with employment status and level of education, i.e. college degree or more identified as the sole risk factors. Since the other independent variables were the same as presented in Table 4, the other results of this additional regression analysis are not presented. Associations between psychological intimate partner violence exposure and bio-psycho-social characteristics of female patients: logistic regression modelling In an additional regression modelling made for female patients without the independent variable disputes in intimate relationship, 33% of the variance were explained , and the only risk factor identified was the patient's unemployment or working part-time . All other independent variables were not significantly associated with psychological IPV exposure, so this additional regression modelling is not presented in a table. --- Discussion The prevalence of psychological IPV of 12.1% during the past year was similar to the prevalence of 10.3% found in the 2012 re-evaluation study of Slovenian family medicine attendees [4], regardless of different time period in question . As stated by Feder et al. [43], asking people about a longer period of time or recent experience can both be potentially problematic; recall bias may be present in responses about a longer period of time, as in the 2012 study [4], while participants in this study, focused on past year violence, might have had insufficient time to acknowledge or identify their abusive experiences as such. It would be fair to conclude that in psychological IPV exposure a prevalence of about 10% is a correct estimation, although it can still be re-evaluated. This prevalence is also concordant with the findings in the WHO multi-country observational study on women's health and domestic violence [44], which reported that between 4%-54% of respondents were exposed to IPV in the year prior to the survey. It was noted that sampling and the time period in question might have led to differences with respect to the gender symmetry of IPV [45,46]. Our findings showed differences in psychological IPV between male and female patients . It has been suggested that men generally experience less threatening and less severe forms of IPV, so they may not consider it particularly salient to remember later in life; similarly, given that women are generally exposed to more severe forms of IPV with higher levels of physical injury, coercive control and fear, they may be more likely to report such violence later in life [46]. Since we explored patients' experiences for only one year previous to the data collection, we do not believe that it affected recall in male participants. Associations between psychological intimate partner violence exposure and health status and the use of health care services Given that psychological abuse often precedes physical abuse [27], and has been found to be as strongly associated with the majority of adverse health outcomes as physical IPV [25], the findings of this study could serve as a useful tool for GPs to aid improved detection of psychological IPV and proper early intervention, although people exposed to psychological IPV have not been shown to use health care services more . The incidence of several, mostly psychological and behavioural status-related conditions , psychosomatic disorders), was found to be significantly higher in psychologically abused patients' medical charts review , which is concordant with the findings of other authors [47][48][49][50]. Psychological IPV was found to be as detrimental as physical IPV in terms of depressive symptoms [51], and also to be a significant predictor of higher levels of IPV-related depression [52]. Women reporting IPV have been shown to be significantly more likely to experience a greater degree of depressive symptoms and functional impairment with lower selfesteem and life satisfaction at five-year follow up [53]. A history of IPV was also found to be positively associated with increased incidence of PTSD symptoms, PTSD diagnoses [54,55], and increased levels of anxiety in women [47,54,56,57]. An association between the severity of anxiety symptoms and co-occurring depression has also been reported, with the severity of anxiety being higher in abused women with depressive symptoms [51]. As expected, gynaecological disorders were more prevalent in the emotionally abused participants of this study , since gynaecological symptoms were also reported to be associated with a history of IPV in many other studies [58][59][60]. However, all of these health conditions were not significantly associated with psychological IPV exposure in multivariate modelling procedures used to partition the variance in a wide variety of indicators of participants' experiences . When discussing these results, adjusted odds ratios between 0.95 > OR < 1.05 were considered as indicative of no association and aORs of 1.05 or greater as risk factors for psychological IPV exposure. In case of aORs of 0.95 or less, with p < 0.05 set as the level of statistical significance, we would have been discussing protective factors for IPV. However, there were none identified. The term risk factor is used loosely to indicate the direction of association with IPV rather than to imply causality, as we have been analysing mainly cross-sectional data. Regardless of gender, most variation was associated with employment status, level of education, an intimate relationship of longer than six years, and a history of disputes in the intimate relationship , while in women, unemployment and a history of disputes in the intimate relationship, identified by the GP in the patient's medical chart review, were also identified as risk factors for psychological IPV exposure . Apart from a college degree, identified as a risk factor in the whole sample, we believe that unemployment, which increases the odds of being exposed to psychological IPV by over five times, could also be considered as a risk factor for the onset of depression and/or anxiety, as diagnosed in 89.5% of IPV-exposed subjects . Otherwise, apart from a genetic predisposition and stressful life events, the known risk factor for depression is a lower socioeconomic status [61,62]. The literature review by Kessler et al. [63] is consistent in showing a strong comorbidity between general anxiety disorder and adult onset of depression, which was the reason we constructed a single variable for the analysis, i.e. The onset of depression and/or generalised anxiety disorder in the medical history . In Slovenia, Klemenc Ketis et al. [64] reported a prevalence of 15.2% patients with depression in the adult population aged between 18 and 64 years. The incidence of depression and/or anxiety in our sample was apparently higher; however, it needs to be further tested in IPV exposed patients at least once more before any valid conclusions can be drawn. --- The harmful impact of employment status In the first quarter of 2012, at the time period in question for this study, the registered unemployment rate, defined as the percentage of unemployed people in the labour force in Slovenia, was 12.3% [65]. In the last four years, the number of employed people in the country was reduced by 70000, while the population of unemployed has grown by 39000; of these, approximately one half was younger than 35 years [65]. In our study, 16.6% of people were unemployed or working part-time , and the percentage is significantly higher in IPV-exposed people compared to those not exposed ; this data obviously shows the unemployment of the study participants as being above the national rate. The official rate of unemployment in this country has been growing from 10.7% in 2010 to 13.6% in 2013, and the trend is expected to continue [65], which should be considered a threat to the well-being of the general population in Slovenia. Unemployment in women and in general was identified as a powerful risk factor for psychological IPV exposure in this study, presumably associated with poverty or at least with the threat thereof. Violence was reported to be frequently used with the aim of resolving conflicts caused by poverty [23]. --- Intimate partnership characteristics and educational attainment as risk factors A history of disputes in the intimate relationship was shown to be the most powerful risk factor . As stated by Jewkes [66], relationships full of conflict, especially those in which conflicts occur about finance, jealousy, and women's gender role transgressions, are more likely to be violent. Educationally, economically, and socially empowered women were found to be the most protected, the relation between empowerment and risk of IPV being presented as non-linear [66]. Contrary to this, in our study sample, a college degree increased the odds of psychological abuse . On 1 January 2012, 19% of Slovenian citizens had tertiary education, i.e. a college degree or higher. Among the employed population, 29% had attained this level of education, while the proportion of highly educated people in the unemployed population was 14% at that time [67]. Of the participants in this study , 45.7% people had attained a college degree or higher; in those exposed to IPV this rate was 52.6%, while among those not exposed it was 44.8% . This rate is apparently well above the national average. Aside from formal marriage, the WHO multi-country study on women's health and domestic violence showed secondary education and a high socio-economic status to be protective factors for IPV exposure [68]. The increased likelihood of better educated participants being exposed to psychological abuse in this study could be explained by their perception and sensibility toward IPV-related behaviour. Whether or not it is reasonable to expect bettereducated people to be less tolerant of psychological IPV due to their increased knowledge, norms, values and expectations, is yet to be discovered. Further exploration, probably based on a qualitative approach, would be needed to test this hypothesis. Since conflicts and disputes in the intimate relationship could have been perceived and interpreted by the patients as psychological IPV itself, additional modelling was performed and employment status identified as a risk factor in both the whole sample and in women only. Aside from the risk factors already discussed, the length of the intimate relationship increased the odds of participants being exposed to psychological IPV, similarly to other findings [37]. However the same was not identified in female patients analysed separately, and although somehow understandable, it needs further verification. --- Implications for family practice and future research Generally, the sample in this study could not be considered as representative of a family medicine attendees' population. In comparison to a representative sample of Slovenian family practice attendees [69], in our sample there were more women , the mean age was slightly younger , and level of education higher . Our results failed to demonstrate that psychological IPV alone is highly detrimental to patients' health, as has been suggested by others [54]. Possible explanation might have been difficulties in managing ethical dilemmas in Slovenian family medicine, given that Klemenc-Ketis et al. [70] found one of the most difficult ethical issues for GPs to be suspicion of physical abuse, sexual abuse, or other criminal behaviour exposure in patients. However, we believe one of the main reasons for our findings was the time period, i.e. current exposure. Moreover, the results are important, as psychological IPV is often still considered a minor type of violence in Slovenia, and consequently receives less attention than physical IPV from clinicians, lawyers, policy makers, researchers and the female victims themselves. Thus, exposure to psychological IPV alone should no longer be considered a minor type of IPV in family medicine practices. More importantly, as stated by Blasco-Ros et al. [54], psychological IPV alone should be considered as less likely to cease than physical IPV or concurrent psychological and physical IPV. Therefore our advice for GPs would be to consider the possibility of exposure to psychological IPV alone in patients who have persistent complaints regarding their psychological and behavioural status . The cross-sectional survey design is inherently limited and, together with reliance on self-reported data, raises questions about the potential for method variance to account for our findings. However, the phenomenon being studied could have been assessed only by asking patients to report their experience or perception, and it was advantageous that this research design incorporated medical records to obtain the exact health related data . Aside from the self-reported data, several characteristics were followed through the longer period of time reviewed by the GPs in the patients' medical history, which we consider mitigated the potential effects of method variance. In the modelling process, data obtained from patients' medical charts for the time prior to psychological IPV screening period and current health status variables were included. This allowed us to explore the effects of early-life characteristics and experiences. Although there were a few factors identified as being associated with psychological IPV exposure, and none of them could be considered as a medical condition, the advantage of this study is the partition of the explained variance . Our finding that health status data from the previous year were not associated with the current psychological IPV exposure suggests the importance of taking this time frame into account when assessing psychological IPV-related health conditions. Prospective studies using clear diagnostic criteria and measures, as well as in-depth, qualitative studies, would be beneficial for extending and deepening our understanding of bio-psycho-social patterns in psychological IPV-exposed patients. We believe that further research should also focus on a longer period of time in order to get more concise characteristics and better grounds for preventive action planning at the societal level and also in the field of family medicine in Slovenia. --- Limitations to the study Data on each GP's drop-out rate was not analysed. Of 960 scheduled patients, 689 attended the interview. One of the reasons for this first drop-out could have been eligibility criteria at the first phase of data collection, i.e. age, the absence of dementia or even mild cognitive impairment, and patients' willingness to participate. Since patients coming for administrative purposes, i.e. chronic patients coming for prescriptions and patients requiring sick leave forms, were also included, their need for health care services could have been fulfilled by getting what they had come for, so later there was no intrinsic motivation for them to attend the scheduled interviews. We believe that the recruitment capacity of GPs could also have been associated with the quality of their relationships with the patients. The question of the validity of GPs' assessment of psychological and behavioural status and its components should also be raised. For the time being, it remains unclear whether or not the onset of depression and/or generalised anxiety disorder, eating and sleeping disorders, phobias and panic attacks, post-traumatic stress disorder and psychosomatic disorders were diagnosed as meeting all relevant criteria and guidelines. Finally, the already-mentioned disadvantage that our findings are not based on a representative sample of family practice attendees in Slovenia should be considered a serious limitation; therefore the identified risk factors could serve as relatively valid guidance for family physicians only in middle-aged, better educated and predominantly female patients. --- Conclusions The prevalence data of psychological IPV exposure in 12.1% of people are concordant with our previous findings in Slovenia. In the sample, the predominance of better-educated people might have been associated with lower tolerance towards psychological IPV. Unemployment in patients should be taken seriously in family medicine attendees, if GPs want to recognise psychological IPV and intervene effectively in individual cases. The state of economical and societal affairs in a country where the unemployment rate is still growing must be acknowledged, and GPs should strengthen their role as their patients' advocates in the broadest meaning of bio-psychosocial well-being. The results of this study, although aimed at exploring gender-related patterns of psychological IPV, warn of the possible damaging impact of employment status, based on prospective data in patients' medical charts. It could be of utmost importance since psychological abuse often precedes other forms of interpersonal violence. --- Abbreviations --- Competing interests The authors declare that they have no competing interests. ---

Background: Intimate partner violence (IPV) is yet to be fully acknowledged as a public health problem in Slovenia. This study aimed to explore the health and other patient characteristics associated with psychological IPV exposure and gender-related specificity in family clinic attendees. Methods: In a multi-centre cross-sectional study, 960 family practice attendees aged 18 years and above were recruited. In 689 interviews with currently-or previously-partnered patients, the short form of A Domestic Violence Exposure Questionnaire and additional questions about behavioural patterns of exposure to psychological abuse in the past year were given. General practitioners (GPs) reviewed the medical charts of 470 patients who met the IPV exposure criteria. The Domestic Violence Exposure Medical Chart Check List was used, collecting data on the patients' lives and physical, sexual and reproductive, and psychological health status, as well as sick leave, hospitalisation, visits to family practices and referrals to other clinical specialists in the past year. In multivariate logistic regression modelling the factors associated with past year psychological IPV exposure were identified, with P < 0.05 set as the level of statistical significance. Results: Of the participants (n = 470), 12.1% (n = 57) were exposed to psychological IPV in the previous year (46 women and 11 men). They expressed more complaints regarding sexual and reproductive (p = 0.011), and psychological and behavioural status (p <0.001), in the year prior to the survey. Unemployment or working part-time, a college degree, an intimate relationship of six years or more and a history of disputes in the intimate relationship, increased the odds of psychological IPV exposure in the sample, explaining 41% of the variance. In females, unemployment and a history of disputes in the intimate relationship explained 43% of the variance.The prevalence of psychological IPV above 10% during the past year was similar to earlier studies in Slovenia, although the predominance of better-educated people might be associated with lower tolerance toward psychological abuse. GPs should pay special attention to unemployed patients and those complaining about family disputes, to increase early detection.

review of the diverse applications of blockchain in the realms of humanitarian aid and social initiatives, examining how this disruptive technology holds the promise to revolutionize the landscape of social good . Humanitarian aid and social initiatives have long grappled with challenges such as transparency, accountability, and inefficiency in resource allocation. Blockchain, with its decentralized and transparent architecture, presents a novel solution to these longstanding issues. The inherent qualities of blockchain, including immutability, security, and transparency, have the potential to transform the way charitable organizations operate, ensuring that aid reaches its intended recipients in a timely and accountable manner. One of the key aspects of blockchain technology lies in its ability to facilitate transparent and tamper-resistant transactions through the implementation of smart contracts. This feature holds immense promise for humanitarian aid, where trust and accountability are paramount. Smart contracts can automate and streamline aid distribution processes, reducing the need for intermediaries and minimizing the risk of corruption. The result is a more direct, efficient, and accountable flow of resources to those in need . Furthermore, blockchain's impact extends beyond the realm of financial transactions. The technology's capability to establish decentralized identity systems enhances the security and verifiability of identities for displaced populations, enabling a more efficient and dignified delivery of aid. Additionally, blockchain's transparency benefits supply chain management, ensuring the traceability of donations from inception to distribution. This not only reduces the risk of fraud but also guarantees the authenticity of goods reaching beneficiaries. As we delve into the myriad applications of blockchain in humanitarian aid and social initiatives, it becomes evident that this technology has the potential to redefine the way we approach social challenges. However, challenges such as scalability, regulatory frameworks, and the need for widespread technological literacy persist. This review seeks to navigate through the current landscape, shedding light on the transformative potential of blockchain for social good, while also recognizing the hurdles that must be addressed to fully harness its benefits. --- Blockchain Technology for Social Good Blockchain technology, initially conceived as the underlying infrastructure for cryptocurrencies, has transcended its financial origins to emerge as a transformative force with far-reaching implications . This paper explores the multifaceted applications of blockchain in the context of social good, specifically focusing on its potential in reshaping humanitarian aid and social initiatives. At its core, blockchain is a decentralized and distributed ledger technology that records transactions across a network of computers. Each transaction, or block, is linked to the preceding one through cryptographic hashes, forming an immutable chain. The decentralization ensures that no single entity has control, and the transparency of the ledger provides a shared and verifiable history of transactions. Smart contracts, self-executing contracts with the terms directly written into code, further enhance blockchain functionality by automating processes and facilitating trustless interactions. The key foreseen innovations and disruptive technologies to tackle challenges of the four directions affected by the COVID-19 pandemic viz food safety, bioactive compounds, food security, and sustainability are shown in figure 1. The examination of blockchain in the context of social good is driven by a confluence of factors rooted in the technology's inherent features and the persistent challenges faced by humanitarian aid and social initiatives. Blockchain's immutable and transparent nature addresses longstanding issues of trust and accountability. In humanitarian aid, where efficient resource allocation is paramount, blockchain's ability to create tamper-resistant transaction histories through smart contracts ensures that aid reaches its intended recipients without the risk of corruption or mismanagement. This increased transparency instills confidence among donors and beneficiaries alike. For many marginalized populations, access to traditional banking services remains elusive. Blockchain's capacity to create decentralized identity systems offers a solution by providing secure and verifiable identities. This is particularly critical in humanitarian scenarios, enabling the efficient delivery of aid to individuals who lack formal documentation due to displacement or crisis . The traditional aid model often involves multiple intermediaries, leading to delays, inefficiencies, and increased costs. Blockchain streamlines this process by removing intermediaries, automating tasks through smart contracts, and ensuring that resources are directed where they are needed most. This disintermediation not only reduces costs but also accelerates response times during crises. Blockchain's impact on humanitarian aid is exemplified by transparent and tamper-resistant transactions. Through smart contracts, the allocation, distribution, and tracking of aid can be automated, reducing the need for intermediaries and minimizing corruption risks. This streamlined process ensures that resources are efficiently deployed and accurately accounted for. In crisis situations, individuals often lose access to essential identification documents. Blockchain facilitates the creation of decentralized identity systems, ensuring that affected populations can establish secure and verifiable identities. This, in turn, expedites aid distribution and supports financial inclusion by providing a basis for accessing banking and financial services. --- Figure 1 The key foreseen innovations and disruptive technologies of COVID-19 pandemic While the potential benefits of blockchain for social good are significant, challenges and considerations must be addressed. Scalability issues, regulatory uncertainties, and the need for widespread technological literacy pose barriers to the widespread adoption of blockchain in social initiatives. Collaborative efforts among researchers, policymakers, and industry stakeholders are crucial to overcoming these challenges and unlocking the full potential of blockchain for social good . In conclusion, blockchain technology holds immense promise in revolutionizing humanitarian aid and social initiatives. By addressing issues of trust, transparency, and efficiency, blockchain has the potential to create a more equitable and accountable global ecosystem for social good. Continued research, collaboration, and innovative applications are essential to fully harness the transformative power of blockchain in the service of humanity. --- Fundamentals of Blockchain Technology In the rapidly evolving landscape of technology, blockchain has emerged as a groundbreaking innovation with profound implications for various industries. At its core, blockchain is a decentralized ledger technology that has revolutionized the way information is stored, shared, and secured. This paper delves into the fundamentals of blockchain, exploring the intricacies of decentralized ledger technology, key features such as transparency, security, and immutability, and the pivotal role played by smart contracts in blockchain applications (Palmié, et. al At its essence, a blockchain is a distributed database that operates on a decentralized network of computers, often referred to as nodes. Unlike traditional centralized databases where a single authority has control, a decentralized ledger distributes control among multiple participants in the network. Each participant, or node, maintains an identical copy of the ledger, ensuring consensus and transparency. When a transaction occurs, it is broadcast to the network and grouped with other transactions into a block. Before being added to the existing chain, each block must undergo a validation process, commonly known as consensus. The consensus mechanism ensures that all nodes agree on the validity of the transaction, eliminating the need for a central authority to validate and authenticate transactions. This decentralized consensus model is fundamental to the trust and security underpinning blockchain technology. Transparency is a hallmark feature of blockchain technology. The ledger is visible to all participants in the network, creating a transparent and accessible record of transactions. Each participant can view the entire transaction history, fostering trust and accountability. In financial transactions, this transparency mitigates fraud and ensures an accurate audit trail . Blockchain achieves security through the use of cryptographic techniques. Each block contains a unique identifier called a hash, generated based on the information within the block and the hash of the previous block. This creates an unbroken chain of blocks, with altering any block requiring the alteration of all subsequent blocks-a practically impossible feat. The decentralized nature of blockchain further enhances security by removing the vulnerability associated with a single point of failure. Immutability is a fundamental property of blockchain, ensuring that once a block is added to the chain, its content cannot be altered or tampered with. The cryptographic hash function plays a pivotal role in guaranteeing immutability, as any change in the block content would result in a completely different hash. Immutability is particularly valuable in maintaining the integrity of historical records, making blockchain a reliable source of truth. Smart contracts are self-executing contracts with the terms directly written into code. They operate on the if-then principle; if a certain condition is met, then a specified action is automatically executed. Deployed on the blockchain, smart contracts facilitate trustless and automated transactions, eliminating the need for intermediaries. The automation enabled by smart contracts brings unparalleled efficiency to various processes. In financial transactions, for example, smart contracts can automate payment processes, reducing the time and cost associated with manual processing. In supply chain management, they can automatically trigger actions based on predefined conditions, such as validating the authenticity of goods or triggering payments upon delivery. Smart contracts foster trustless interactions by executing actions automatically when conditions are met, without the need for intermediaries or third parties. This not only reduces the risk of fraud but also streamlines processes by eliminating the delays and complexities associated with traditional contractual agreements. While the fundamentals of blockchain technology present a promising landscape, challenges such as scalability, regulatory uncertainties, and the need for widespread adoption remain. Scalability issues, in particular, must be addressed to ensure that blockchain can handle the increasing volume of transactions without compromising efficiency. In conclusion, understanding the fundamentals of blockchain technology is essential to grasp the transformative potential it holds. Decentralized ledger technology, coupled with key features like transparency, security, and immutability, lays the foundation for a new era of secure and transparent transactions. Smart contracts further enhance the utility of blockchain, providing a mechanism for trustless and automated interactions. As we navigate through the complexities of blockchain, it becomes evident that this technology is not merely a buzzword but a fundamental shift in the way we conceptualize and implement secure and transparent digital transactions. The ongoing evolution of blockchain technology promises to reshape industries, foster innovation, and redefine the way we engage with information and value. --- Blockchain in Humanitarian Aid Humanitarian aid, often marked by urgency and a need for transparency, faces numerous challenges in ensuring efficient, secure, and accountable resource distribution. Blockchain technology has emerged as a powerful tool in transforming the landscape of humanitarian aid, offering solutions to persistent issues . This paper explores the application of blockchain in humanitarian aid, focusing on transparent and tamper-resistant transactions and the implementation of decentralized identity systems. Blockchain's integration of smart contracts revolutionizes the distribution of aid by automating and securing the entire process. Smart contracts are self-executing contracts with predefined rules and conditions written into code. In the context of humanitarian aid, these contracts automate the release of funds and resources based on predetermined criteria, eliminating the need for manual intervention. Smart contracts facilitate immediate and automatic responses to predefined triggers. For instance, when a certain condition is met, such as reaching a specific number of beneficiaries or achieving a particular project milestone, funds are automatically disbursed. This automation reduces delays, ensuring that aid reaches those in need promptly. Traditional aid distribution involves multiple intermediaries, leading to increased costs and higher corruption risks. By leveraging blockchain's smart contracts, direct peer-to-peer transactions are enabled. This reduction in intermediaries not only minimizes the risk of corruption but also cuts down on administrative overheads, ensuring a more efficient and direct flow of resources. Blockchain technology addresses a critical issue in humanitarian aid by providing decentralized identity systems, offering secure and verifiable identities for displaced populations. Displaced populations often lack proper identification, hindering their ability to access essential services . Blockchain's decentralized identity systems enable the creation of secure and verifiable digital identities. Each individual can have a unique digital identity stored on the blockchain, accessible and immutable, thereby overcoming the challenges associated with physical documentation loss during displacement. The implementation of decentralized identity systems facilitates more efficient and dignified aid delivery. Aid organizations can verify the identities of recipients without the need for traditional documents, streamlining the distribution process. This not only enhances the speed of aid delivery but also preserves the dignity of beneficiaries by eliminating the need for extensive paperwork or cumbersome verification processes. Several real-world applications of blockchain in humanitarian aid underscore the transformative impact of this technology . The World Food Programme implemented the Building Blocks project, leveraging blockchain to enhance efficiency in cash-based transfers for refugees. Through blockchain, the WFP ensured secure and transparent transactions, reducing fraud and ensuring that aid reached the intended recipients. UNICEF's Project Connect focuses on providing connectivity to every school worldwide. By utilizing blockchain technology, UNICEF aims to create a decentralized identity for every school, ensuring that each educational institution has a verifiable and secure identity. This initiative streamlines the distribution of resources, enabling efficient and targeted support to schools in need. While blockchain holds immense promise for humanitarian aid, challenges such as scalability, regulatory frameworks, and technological literacy persist. The scalability of blockchain networks is crucial to handle the increasing volume of transactions in large-scale humanitarian operations. Additionally, clear regulatory frameworks are needed to ensure the legality and acceptance of blockchain applications in the humanitarian sector. Moreover, efforts to enhance technological literacy among aid organizations and beneficiaries are essential for the successful implementation and adoption of blockchain solutions . Blockchain technology has the potential to revolutionize humanitarian aid, addressing longstanding challenges in transparency, efficiency, and identity verification. Transparent and tamper-resistant transactions, facilitated by smart contracts, streamline aid distribution, reduce corruption risks, and ensure timely responses. Decentralized identity systems empower displaced populations with secure and verifiable identities, fostering efficient and dignified aid delivery. As blockchain continues to evolve, ongoing research, collaboration, and the development of scalable solutions are crucial to fully realize its transformative impact in humanitarian aid, paving the way for a more equitable and efficient global response to crises . --- Supply Chain Transparency Supply chain transparency is a pivotal factor in ensuring the effectiveness and integrity of humanitarian aid and business operations alike. The advent of blockchain technology has brought forth a transformative solution to the challenges associated with supply chain management. This paper delves into the ways blockchain enhances supply chain transparency, specifically focusing on the traceability of donations and its profound impact on reducing fraud in supply chain management and guaranteeing the authenticity of goods reaching beneficiaries . In humanitarian aid and various industries, ensuring the authenticity of goods is paramount. Blockchain offers a robust solution to guarantee the legitimacy and safety of products within the supply chain. Each product within the supply chain can be assigned a unique identifier, and its journey from manufacturing to distribution is recorded on the blockchain. This creates an immutable record of every stage, providing stakeholders with a transparent and unalterable history of each product. Counterfeiting and tampering are mitigated as beneficiaries and stakeholders can verify the authenticity of goods through these unforgeable records. Blockchain enables real-time tracking of goods, allowing stakeholders to monitor the movement of products at each stage of the supply chain. This proactive approach to tracking reduces the likelihood of counterfeit goods entering the supply chain and ensures that beneficiaries receive genuine and safe items. Several notable initiatives have successfully utilized blockchain to enhance supply chain transparency and address issues of fraud and authenticity. Everledger employs blockchain to trace the origin and journey of diamonds, ensuring authenticity and reducing the risk of trade in conflict or illicit diamonds. While not directly related to humanitarian aid, this initiative illustrates the broader potential of blockchain in verifying the authenticity of goods within a supply chain. Provenance uses blockchain to trace the supply chain of food products, providing consumers with information about the origin, journey, and ethical considerations of the products they purchase. This use case highlights how blockchain can be applied to ensure the authenticity and transparency of goods, which is equally relevant in humanitarian aid scenarios. Despite the promises of blockchain in supply chain transparency, challenges such as scalability, interoperability, and the integration with existing systems need attention. Scalability is vital for accommodating the vast number of transactions within large-scale supply chains. Interoperability ensures seamless collaboration between different blockchain platforms and traditional supply chain systems, fostering comprehensive transparency . Blockchain technology stands as a beacon for advancing accountability and transparency in supply chain management. The traceability of donations through blockchain significantly reduces fraud, enhancing the integrity of supply chains in humanitarian aid and beyond. Furthermore, guaranteeing the authenticity of goods reaching beneficiaries is paramount for ensuring the safety and efficacy of aid efforts. As technology evolves, continued research, collaboration, and practical implementations are essential to overcoming challenges and unlocking the full potential of blockchain in revolutionizing supply chain transparency. The transformative impact of blockchain on supply chains signifies a new era of accountability and trust in the global movement of goods and aid. --- Social Initiatives and Decentralized Autonomous Organizations In the landscape of social initiatives, the advent of blockchain technology has given rise to innovative models of governance and community-driven collaboration. Decentralized Autonomous Organizations stand at the forefront of this evolution, offering a novel approach to collective decision-making, resource management, and fostering a sense of empowerment and ownership within communities. This paper explores the transformative potential of DAOs in social initiatives, delving into their foundational principles and the ways in which they incentivize positive behaviors through token economies. Decentralized Autonomous Organizations are entities that operate on blockchain technology, governed by smart contracts and characterized by a decentralized decision-making structure. Unlike traditional organizations with hierarchical structures, DAOs rely on the collective intelligence and consensus of their members to make decisions and manage resources. The core principles of transparency, decentralization, and trustless interactions define the essence of DAOs . DAOs fundamentally alter the governance paradigm by shifting decision-making authority from a centralized body to a decentralized network of participants. Each member typically has voting power proportional to their stake in the DAO, ensuring a democratic and inclusive decision-making process. Smart contracts, self-executing contracts with predefined rules, play a pivotal role in DAOs. These contracts automate various aspects of decision-making and resource allocation. For example, a DAO might use smart contracts to automatically distribute funds for approved projects based on the consensus of its members. DAO members can submit proposals outlining initiatives, projects, or resource needs. The community then votes on these proposals, and if accepted, the smart contracts execute the allocation of resources accordingly. This collective decision-making mechanism ensures that community members have a direct say in the direction and impact of social initiatives . DAOs foster inclusive participation, allowing individuals from diverse backgrounds to contribute and influence decision-making. This inclusivity ensures that a variety of perspectives and experiences are considered when shaping the direction of social initiatives. DAO members have a direct stake in the success of the initiatives. As owners of the DAO, they are invested not only financially but also emotionally in the outcomes. This sense of ownership fosters a greater commitment to the success of social initiatives, leading to increased accountability and engagement. The absence of a central authority in DAOs means that leadership emerges organically from the community. This decentralized leadership model encourages collaboration, shared responsibility, and the cultivation of leadership skills within the community, empowering individuals to take on meaningful roles. DAOs often employ token economies to incentivize positive behaviors that contribute to the success of social initiatives. Members may receive tokens as rewards for active participation, successful project contributions, or other positive actions within the community. The use of tokens aligns individual incentives with the broader goals of the DAO. As members accumulate tokens, they gain more influence in decision-making processes, creating a self-reinforcing cycle where positive contributions lead to increased influence, encouraging sustained engagement. Token economies in DAOs can prioritize social impact by rewarding activities that align with the mission of the organization. For example, a DAO focused on environmental sustainability might incentivize actions that contribute to carbon reduction, afforestation, or clean energy projects . Several successful DAOs in the realm of social initiatives showcase the practical implementation of these principles. MolochDAO is a decentralized grant-giving DAO focused on supporting Ethereum development projects. Members pool funds, collectively decide on grant allocations, and use token-based voting to determine project funding. This DAO exemplifies the power of decentralized decision-making and resource allocation. Giveth is a decentralized platform for building and funding charitable projects. It operates as a DAO, enabling transparent and community-driven governance. Giveth uses tokenomics to incentivize positive contributions, aligning individual interests with the broader mission of supporting social initiatives . While DAOs offer a revolutionary approach to social initiatives, challenges such as governance scalability, legal frameworks, and user education need to be addressed. Overcoming these challenges will be crucial for the continued growth and impact of DAOs in driving positive change. Decentralized Autonomous Organizations represent a paradigm shift in the way social initiatives are governed and executed. By fostering collective decision-making, empowering communities, and implementing token economies, DAOs create a dynamic and inclusive model for achieving positive social impact. As the landscape of social initiatives continues to evolve, DAOs stand as a beacon of decentralized collaboration, enabling communities to drive meaningful change with ownership, transparency, and shared incentives at its core. --- Challenges and Considerations While the potential of blockchain for social good is immense, the journey is not without its challenges. This paper explores key hurdles and considerations, ranging from scalability issues and regulatory uncertainties to addressing technological literacy barriers, that must be navigated to unlock the full transformative power of blockchain in serving societal needs. One of the primary challenges facing blockchain technology is its inherent scalability limitations. Traditional blockchain networks, like Bitcoin and Ethereum, struggle with processing a high volume of transactions per second. As social good initiatives scale up, the demand for increased transaction throughput becomes crucial to accommodate the growing number of participants and transactions . The proof-of-work consensus mechanism, employed by some blockchains, contributes to scalability challenges due to its energy-intensive nature. As the network expands, the environmental impact of mining activities becomes a concern. Transitioning to more sustainable consensus mechanisms, such as proof-of-stake, is a potential solution but requires widespread adoption and consensus among stakeholders. As the number of users and transactions on a blockchain increases, network congestion becomes a prevalent issue. Slow transaction confirmations and higher fees during peak times can hinder the efficiency of social initiatives relying on blockchain, affecting the user experience and potentially discouraging participation. The regulatory landscape surrounding blockchain technology is currently evolving, presenting uncertainties and challenges for social good applications. Varied and often ambiguous regulations worldwide contribute to a lack of standardized legal frameworks. The absence of clear guidelines on compliance, taxation, and legal recognition may impede the adoption and growth of blockchain initiatives in the social sector. Blockchain's transparent and immutable nature can clash with evolving data protection regulations, such as the European Union's General Data Protection Regulation . Balancing the transparency benefits of blockchain with individuals' right to privacy poses a challenge, as blockchain transactions are typically publicly accessible and permanent. Governments and regulatory bodies may exhibit a level of caution or hesitation in embracing blockchain technology due to its relatively recent emergence. Regulatory lag, the delay in adapting laws to accommodate technological advancements, may result in an uncertain environment for social initiatives seeking to leverage blockchain for positive societal impact. Blockchain technology can be complex, requiring a certain level of technical understanding for effective utilization. Social initiatives often involve diverse stakeholders, including non-technical participants, who may find the intricacies of blockchain challenging to comprehend. Bridging this knowledge gap is crucial for fostering widespread adoption. The user interface and experience of blockchain applications play a vital role in overcoming technological literacy barriers. Developing intuitive and user-friendly interfaces that paper the complexity of blockchain technology can enhance accessibility and encourage broader participation in social initiatives. Promoting technological literacy through educational initiatives is paramount. Training programs, workshops, and awareness campaigns can empower individuals, organizations, and communities to understand the potential of blockchain for social good and equip them with the skills needed for effective engagement. UNICEF's Innovation Fund, while not directly focused on blockchain, highlights the challenges of implementing new technologies in the social sector. The fund invests in startups developing open-source solutions that can benefit children globally. Bridging the gap between technology and social impact requires navigating challenges, including scalability and regulatory considerations. Initiatives like the Self-Sovereign Identity movement aim to empower individuals with control over their digital identities. These projects face challenges in educating users about the advantages of decentralized identity solutions and addressing regulatory concerns related to identity verification . Advancements in blockchain technology, such as layer-two scaling solutions and alternative consensus mechanisms, are actively being explored to address scalability issues. The industry's collaborative efforts and research endeavors aim to enhance the capacity of blockchain networks, making them more robust and scalable for social initiatives. Collaborative efforts between blockchain industry stakeholders, social initiatives, and regulatory bodies are essential for creating a conducive regulatory environment. Proactive engagement, advocacy, and dialogue can contribute to the development of clear and supportive regulatory frameworks that foster innovation and responsible blockchain use for social good. Empowering communities through educational initiatives and community engagement is key to overcoming technological literacy barriers. Organizations and projects should prioritize user education, offering resources, training, and support to ensure that participants feel confident in utilizing blockchain for social impact . While challenges persist in harnessing the full potential of blockchain for social good, the commitment to overcoming these obstacles through collaboration, innovation, and education remains strong. Addressing scalability issues, navigating regulatory uncertainties, and enhancing technological literacy are crucial steps toward creating a more inclusive, transparent, and impactful future where blockchain serves as a catalyst for positive societal change. As the technology matures and stakeholders work collectively to overcome these challenges, the transformative impact of blockchain on social initiatives is poised to reach new heights. --- Case Studies Blockchain technology has transcended its origins in cryptocurrency to become a catalyst for positive change in humanitarian aid and social initiatives . This paper explores case studies that showcase successful applications of blockchain in addressing challenges, enhancing transparency, and fostering innovation in the realms of humanitarian aid and social impact initiatives. The World Food Programme initiated the Building Blocks project to revolutionize cash-based transfers in humanitarian aid using blockchain. Building Blocks leverages blockchain to streamline the distribution of cash assistance to beneficiaries. By recording transactions on a transparent and immutable blockchain, the project ensures the traceability of funds, reducing the risk of fraud and corruption. The success of Building Blocks demonstrates how blockchain enhances accountability and efficiency in humanitarian aid, ultimately leading to more impactful assistance for those in need. UNICEF's Project Connect is a prime example of leveraging blockchain for social good by focusing on connectivity for schools worldwide. The initiative aims to create a decentralized identity for every school, ensuring that each educational institution has a verifiable and secure identity on the blockchain. This decentralized identity system facilitates efficient and transparent resource allocation, streamlining the distribution of funds, and ensuring that educational institutions receive the support they need. Project Connect exemplifies how blockchain can be a game-changer in enhancing transparency and accountability in the allocation of resources for social causes. Giveth is a decentralized platform that utilizes blockchain technology to transform charitable giving. By creating a transparent and traceable donation ecosystem, Giveth ensures that donors have visibility into how their contributions are utilized. Smart contracts automate the distribution of funds based on community-approved proposals, reducing the need for intermediaries. Giveth showcases how blockchain empowers individuals to directly contribute to social initiatives while fostering trust and accountability within the decentralized ecosystem. Kiva, a nonprofit organization focused on financial inclusion, has embraced blockchain technology to enhance its microlending platform. The Kiva Protocol utilizes blockchain to create a decentralized identity system for individuals lacking traditional documentation. This innovative approach enables marginalized populations to establish secure and verifiable identities, unlocking access to financial services. By leveraging blockchain, Kiva enhances financial inclusion and empowers individuals in underserved communities to participate in the global economy. The Human Rights Foundation utilizes blockchain technology to support human rights activists and promote financial sovereignty. Through the Bitcoin Development Fund, HRF channels funds to support developers working on privacy-focused and censorship-resistant technologies. Blockchain, specifically Bitcoin in this case, serves as a tool for financial autonomy, enabling activists in restrictive environments to access resources without dependence on traditional financial institutions. This case demonstrates how blockchain can be a powerful tool for promoting human rights and empowering individuals to resist censorship. These case studies collectively highlight the transformative impact of blockchain in fostering transparency and accountability. Whether in humanitarian aid or social initiatives, the use of blockchain ensures that transactions, resource allocations, and fund disbursements are transparent, traceable, and resistant to tampering. This transparency builds trust among stakeholders, including donors, beneficiaries, and the wider community. Blockchain's ability to automate processes through smart contracts contributes to increased efficiency in resource management. Smart contracts streamline the allocation of funds, automate verification processes, and eliminate the need for intermediaries. This automation not only reduces operational costs but also accelerates the pace at which aid is delivered and social initiatives are executed. Blockchain facilitates empowerment and financial inclusion by creating decentralized identity systems. Whether in educational initiatives, micro-lending platforms, or human rights advocacy, blockchain empowers individuals with secure and verifiable identities. This empowerment is foundational to financial inclusion, enabling marginalized populations to access essential services, participate in economic activities, and assert their rights. While these case studies exemplify successful applications of blockchain in humanitarian aid and social initiatives, challenges such as scalability, regulatory uncertainties, and technological literacy barriers persist. Overcoming these challenges requires ongoing collaboration, research, and advocacy to ensure that the potential of blockchain is fully realized for the benefit of society . The case studies presented underscore the transformative potential of blockchain in reshaping humanitarian aid and driving positive social impact. From transparent and traceable cash transfers to decentralized identity systems and innovative charitable giving platforms, blockchain technology is proving to be a powerful force for good. As these success stories continue to inspire and inform, the collective efforts of stakeholders, including governments, organizations, and communities, are crucial to overcoming challenges and realizing the full potential of blockchain in creating a more equitable and transparent world. --- Future Directions As blockchain technology continues to evolve, its potential for catalyzing positive change in social good initiatives becomes increasingly evident. To ensure the continued growth and success of blockchain in this domain, it is crucial to address research gaps, provide policy recommendations, and foster collaborative efforts for ongoing innovation. This paper explores future directions and recommendations to guide the trajectory of blockchain in serving societal needs. One prominent area for further exploration lies in scalability solutions for blockchain networks. As social initiatives scale up, the need for networks capable of handling a high volume of transactions becomes paramount. Research into novel consensus mechanisms, layer-two scaling solutions, and interoperability protocols is essential to address the scalability challenges associated with widespread adoption . Research focusing on the environmental impact of blockchain technology is imperative. While the technology holds promise, the energy consumption associated with certain consensus mechanisms, such as proof-of-work, raises concerns. Investigating and implementing eco-friendly consensus mechanisms will contribute to the long-term sustainability of blockchain solutions for social good. Exploring effective governance models for decentralized autonomous organizations is an area that warrants attention. The development of robust frameworks for decision-making, dispute resolution, and accountability within DAOs will enhance their functionality and resilience. Research into inclusive governance structures that accommodate diverse stakeholder perspectives will be instrumental in ensuring the success of DAO-driven social initiatives. Research focusing on improving the user experience of blockchain applications is vital for broader adoption. Simplifying user interfaces, enhancing educational resources, and conducting user-centric studies can help bridge the technological literacy gap. Understanding user motivations, preferences, and pain points will contribute to the creation of more accessible and user-friendly blockchain solutions for social initiatives. Policymakers should work towards establishing clear and supportive regulatory frameworks for the integration of blockchain in social good initiatives. Providing legal clarity on issues such as smart contract enforceability, data protection, and tax implications will foster a conducive environment for innovation while ensuring compliance with existing laws. Policymakers should encourage interdisciplinary collaboration between government agencies, blockchain experts, and social organizations. Collaborative initiatives can help design policies that balance the innovative potential of blockchain with the need for regulatory oversight. Engaging stakeholders from diverse fields will result in well-informed and inclusive policies.Governments can consider offering incentives for responsible blockchain innovation in the social sector. This might include grants, tax incentives, or regulatory sandboxes that allow organizations to experiment with blockchain solutions without facing immediate regulatory constraints. Such incentives can stimulate responsible experimentation and accelerate the development of impactful social initiatives.Policymakers should proactively address data privacy concerns associated with blockchain technology. Striking a balance between the transparency benefits of blockchain and individuals' right to privacy is crucial. Creating guidelines for privacy-focused implementations and ensuring compliance with existing data protection regulations will build trust in blockchain applications for social good. The transformative potential of blockchain in addressing global challenges requires international collaboration. Governments, NGOs, businesses, and academic institutions should collaborate on a global scale to share insights, best practices, and lessons learned. Cross-border partnerships can accelerate the development and deployment of blockchain solutions that have a meaningful impact on a global scale. Engaging a diverse set of stakeholders is key to the success of blockchain in social initiatives. Governments, industry leaders, academia, and civil society organizations should come together to form multi-stakeholder coalitions. These coalitions can facilitate dialogue, share resources, and collaboratively address challenges, ensuring a holistic and inclusive approach to blockchain implementation. Continued investment in education and training programs is essential to build a skilled workforce capable of driving blockchain innovation. Governments, educational institutions, and industry partners should invest in initiatives that promote blockchain literacy, skill development, and knowledge transfer. This investment will empower individuals to contribute meaningfully to the ongoing development of blockchain solutions. Governments and philanthropic organizations should provide support for pilot projects that explore the application of blockchain in diverse social contexts. Funding, mentorship, and access to resources can help these projects navigate challenges and demonstrate the real-world impact of blockchain technology. Supporting early-stage initiatives will foster a culture of innovation and experimentation . The future of blockchain in serving social good is both promising and challenging. By addressing research gaps, implementing thoughtful policy recommendations, and fostering collaborative efforts, we can navigate these challenges and unlock the full potential of blockchain technology. The evolution of blockchain for social impact relies on a collective commitment to innovation, inclusivity, and responsible deployment. As we embark on this journey, the continued collaboration between technologists, policymakers, and communities will shape a future where blockchain contributes significantly to positive societal transformation. --- Recommendation Throughout this review, we have delved into the transformative applications of blockchain in humanitarian aid and social initiatives. Notable case studies, such as the World Food Programme's Building Blocks project and UNICEF's Project Connect, have exemplified how blockchain enhances transparency, accountability, and efficiency in resource allocation. From decentralized identity systems to smart contracts automating aid distribution, blockchain has demonstrated its potential to revolutionize the landscape of social good. The findings underscore a resounding affirmation of blockchain's transformative potential for social good. The technology's inherent features, including transparency, immutability, and decentralized governance, address critical challenges in humanitarian aid and social initiatives. Blockchain empowers communities, enhances accountability, and streamlines processes, offering a paradigm shift in how we approach and implement social impact initiatives. As we conclude this review, it is essential to emphasize the significance of continued research and implementation efforts in harnessing blockchain for social good. The journey has only just begun, and there are still challenges to overcome, such as scalability issues, regulatory uncertainties, and technological literacy barriers. However, these challenges should be viewed as opportunities for growth and refinement. Ongoing research should focus on scalability solutions to accommodate the growing demands of humanitarian aid and social initiatives. Exploring alternative consensus mechanisms, layer-two scaling solutions, and interoperability protocols will contribute to the development of more robust and scalable blockchain networks.Policymakers and researchers should collaborate to establish clear regulatory frameworks that facilitate the integration of blockchain in social good initiatives. Addressing legal uncertainties, data privacy concerns, and ensuring compliance with existing laws will create a supportive environment for blockchain innovation. Efforts should be intensified to bridge the technological literacy gap, making blockchain more accessible to a wider audience. Educational initiatives, user-friendly interfaces, and community engagement play crucial roles in empowering individuals and organizations to leverage blockchain technology effectively. The global community should encourage innovation that transcends geographical boundaries. Collaborative efforts between governments, NGOs, businesses, and academia will foster a culture of innovation with a global impact. Investing in pilot projects, supporting grassroots initiatives, and sharing best practices will contribute to a more inclusive and diverse blockchain ecosystem. In envisioning the future, blockchain stands as a powerful tool for positive societal transformation. The potential to create decentralized, transparent, and inclusive systems that empower individuals and communities is unprecedented. As we move forward, let us collectively commit to realizing this vision by embracing the principles of collaboration, innovation, and ethical deployment of blockchain technology. --- Conclusion In conclusion, blockchain for social good is not merely a concept but a tangible force driving change. The success stories showcased in this review illuminate the path forward, and the potential for even greater impact is within our grasp. Let us build upon these foundations, learn from challenges, and work collaboratively to shape a future where blockchain serves as a catalyst for positive and sustainable social change. Through ongoing research, thoughtful implementation, and a shared commitment to making a difference, blockchain can truly be a force for good in the service of humanity. --- Compliance with ethical standards --- Disclosure of conflict of interest No conflict of interest to be disclosed.

Blockchain technology has emerged as a revolutionary force with the potential to address pressing social challenges and transform traditional paradigms in humanitarian aid and social initiatives. This paper provides a comprehensive review of the diverse applications of blockchain in fostering social good, particularly in the realms of humanitarian aid and social initiatives. The decentralized and transparent nature of blockchain offers a paradigm shift in the way charitable organizations operate and deliver aid. Smart contracts on blockchain enable transparent and tamperresistant transactions, ensuring that resources are allocated efficiently and reach intended beneficiaries. The elimination of intermediaries reduces the risk of corruption and ensures a more direct and accountable flow of funds. In the context of humanitarian aid, blockchain facilitates the creation of decentralized identity systems, ensuring secure and verifiable identities for displaced populations. This aids in the efficient delivery of aid, as well as financial inclusion for those without access to traditional banking services. Moreover, blockchain enhances supply chain transparency, enabling the tracking of donations from inception to distribution, reducing fraud and ensuring the authenticity of goods. Social initiatives, too, benefit from blockchain's transformative capabilities. Decentralized autonomous organizations (DAOs) enable communities to collectively make decisions and manage resources. This fosters a sense of ownership and empowerment among participants, promoting sustainable social development. Additionally, blockchain-based token economies incentivize positive behaviors, encouraging individuals to contribute to social causes in meaningful ways. Despite these promising applications, challenges such as scalability, regulatory uncertainties, and technological literacy remain. This paper calls for continued research and collaboration to unlock the full potential of blockchain for social good, emphasizing the need for innovative solutions that can address the unique challenges faced by humanitarian and social initiatives.

Less is known about differences between immigrant-and nonimmigrant FEP patients in functional-and symptomatic outcome of psychotic disorders, and how these relate to differences in baseline illness dimensions. Early studies suggested better prognosis among immigrant FEP patients in the United Kingdom, perhaps related to a relatively more affective and acute profile of psychosis in these groups ), but a recent review of UK studies concluded that there is insufficient evidence of high quality . A Dutch study found a comparable functional outcome after 2 years in Dutch and immigrant FEP patients . To our knowledge, there are no studies that have investigated differences between immigrant-and non-immigrant FEP patients across the full range of illness dimensions and subsequently linked them to symptom remission and functional outcome domains like vocational/ academic performance, personal relationships; self-care and disturbing behaviour . To investigate variability in symptom expression in psychosis and the impact of baseline illness dimensions on functional-and symptomatic outcome, a multi-dimensional approach of psychotic disorders, psychopathology as well as social functioning is required . Five primary symptom dimensions have been proposed within the psychosis spectrum: psychosis; negative symptoms; cognitive symptoms ; emotional distress and excitement/mania . Of these dimensions, severe negative symptoms and impaired cognitive functioning are generally associated to poorer outcome , whereas predominant affective symptoms and excitement are associated to better outcome . --- | Aims of the study The primary aim of the present study was to examine differences in symptom expression, neurocognitive and social cognitive performance, and psychosocial functioning between Dutch, first-generation immigrants and second-generation immigrants with a first-episode psychosis at first presentation in a large sample of patients with first-episode psychosis. The secondary aim was to examine functional and symptomatic change and between-group differences at 12months follow-up. Furthermore, associations between migration subgroup membership, baseline characteristics and both functional and symptomatic outcome were explored. --- | MATERIAL AND METHOD --- | Classification of ethnicity Concepts such as "ethnicity" are intrinsically hard to capture in a single variable. A wide range of conceptual en methodological approaches have been used to capture this concept . In the present study "ethnicity" was operationalized using to the criteria of Dutch Bureau of Statistics , as are commonly used for studies conducted in The Netherlands . Using this approach, data were collected for all patients on their country of birth and the country of birth of both their biological parents. Subsequently, patients who were born in The Netherlands with 2 parents who were also born in the The Netherlands, were classified as Dutch. Those who were born in The Netherlands and had at least 1 parent born abroad, were categorized as second-generation immigrant, and those who were born abroad, were categorized as first-generation immigrant. --- | Subjects The study was conducted in the period December 1, 2009 to December 31, 2012. Inclusion criteria: all patients who were referred to the department for non-affective early psychosis in The Hague, were diagnosed with a psychotic disorder, were included in the study. Exclusion criteria: patients were excluded if they did not complete the assessment procedures at baseline, did not complete the assessment procedures at 12-months follow-up. The diagnostic protocol is described in full details elsewhere . The study sample consisted of 162 patients diagnosed with a first episode of a psychotic disorder . In total, 46 patients were classified as "Dutch," 56 as 'second-generation immigrant" Surinam, Turkey, western countries, for example, northern, southern or western Europe, the former Yugoslavia, the USA, Canada, Australia, New Zealand, Japan or former Netherlands East Indies and all other countries. --- | Cognitive performance A comprehensive psychological test-battery was construed to assess the symptom dimensions neurocognitive and social cognitive functioning. Neurocognitive assessment included assessment of the subdomains attention , problem solving speed of processing , verbal fluency , verbal learning , visual learning , working memory and general cognition . Social cognition measures included assessment of the subdomains emotion perception , theory of mind , social knowledge and social cognitive biases . There is currently no clear consensus on what task or tasks should be used to assess social knowledge in the early stages of psychosis . We argue that the WAIS-III picture arrangement task taps into the construct of social knowledge, since it assesses knowledge about relationships between an individual's thoughts, feelings, behavioural actions and related responses or consequences in social context. --- | Symptoms dimensions We used the Positive and Negative Syndrome Scale to assess positive and negative symptoms as well as general psychopathology. Six symptom dimensions were computed: positive symptoms; negative symptoms; neurocognitive functioning; social cognitive functioning; excitement and emotional distress . --- | Psychosocial functioning The Personal and Social Performance scale was used to assess dimensions of psychosocial functioning . The PSP uses 4 subscales to assess problems in specific social functioning domains: Social useful activities including study and work , Personal and social relationships , Self-care and care for personal environment and Disturbing and/or aggressive behaviour . Higher subscale scores reflect more problems. --- | Data analysis The analyses were performed in SPSS version 22. To assess the 4 symptom dimensions, we followed the 5-factor model to restructure the related items from the Positive and Negative Syndrome Scale , as described by Van der Gaag et al. . Their cross-validation of the PANSS items yielded 25 items that loaded on the same factor in all 10 examined datasets. We used these items to present the following symptom dimension through 4 single-solution confirmatory factor analyses: positive symptoms , negative symptoms , excitement and emotional distress . To obtain 1 variable for symptomatic outcome, the remission tool variable was computed by adding the 8 related PANSS items form the PANSS . Scores per cognitive task were standardized for each cognitive variable using normative data and then averaged per cognitive subdomain . To further reduce the number of cognitive variables, the sets of neurocognitive and social cognitive variables were collapsed into 2 separate variables using 2 singlesolution confirmatory factor analyses . ANOVA was used to assess between-group differences on demographic variables. To further explore these differences, significant findings were followed up with independent sample t tests between groups. Non-parametric tests were used to assess differences between groups on gender. ANCOVA was used to assess between-group differences on psychopathological-, cognitive-and psychosocial functioning scores, using demographic variables that significantly differed between groups as covariates . To further explore these differences, significant findings were again followed up with independent sample t tests between groups. ANCOVA was used to assess between-group differences on functional-and symptomatic outcome . Within-group functional-and symptomatic changes between baseline and 12months follow-up were assessed for the 3 groups using general linear models. To explore predictors of both functional-and symptomatic outcome, we constructed backward regression models predicting functional and symptomatic outcome at 12-months follow-up, including all baseline demographic-, cognitive-, symptom dimensions and migration subgroup membership as predictors in all models . As a post-hoc examination of possible language-related assessment bias in our study, scores on verbal learning and visual learning were compared within each of the study groups using general linear models. --- | RESULTS --- | Diagnoses and demographic data Distribution of the schizophrenia and psychotic disorder NOS diagnoses were equally distributed across the study groups . Demographic variables for Dutch, second-and firstgeneration immigrants on demographic variables are presented in Table 1. The 3 groups showed significant differences on age, annual income, years of education and ethnic density. Second-generation immigrants were younger on average at first contact compared to both other groups. Dutch patients had a higher average income than second-generation immigrants, and the latter had a higher average income than first-generation immigrants. First-generation immigrants received less education on average compared to both other groups. Dutch patients more often resided in an area of the city where they belonged to the ethnic majority, where immigrants more often resided in an area of the city where they belonged to an ethnic minority . --- | Neurocognition and social cognition Mean standardized scores for neurocognitive and social cognitive subdomains for Dutch, second-and first-generation immigrants are presented in Table 2. Examination of neurocognitive and social cognitive differences between these groups showed marked differences . These differences showed a distinct pattern, where Dutch had smaller deficits than second-generation immigrants, where the latter had smaller deficits than first-generation immigrants. Only deficits in social cognitive biases and facial affect perception did not differ between groups. The observed differences all remained significant after adjusting for age, income, years of education and ethnic density . --- | Psychopathology and psychosocial functioning Scale scores for positive symptoms, negative symptoms, excitement, emotional distress and the SCI-SR at baseline and at 12-months follow-up for Dutch, second-and first-generation immigrants are presented in Table 3. Mean scores for general psychosocial functioning, and deficits in work and study, social relationship, self-care and disturbing behaviour at baseline and at 12-months follow-up for these groups are presented in Table 4. --- | Psychopathology at baseline and 12-months follow-up Within-group comparison of the 4 symptom dimensions and the SCI-SR showed that all patient groups showed symptomatic improvement in the first 12 months after diagnosis across all domains, except for negative symptoms . The level of positive symptoms lowered in second-generation immigrants, where the level of excitement lowered in Dutch and second-generation immigrants. Levels of emotional distress lowered in all 3 groups, where Dutch and secondgeneration immigrants also obtained significantly higher rates of overall remission. Analysis of between-group differences in symptoms at baseline yielded no significant differences, controlling for age, income, years of education and ethnic density . At 12-months follow-up the study groups showed significant differences on negative symptoms , where post-hoc analysis showed that Dutch patients had fewer negative symptoms than both other groups . --- | Psychosocial functioning at baseline and 12months follow-up Within-group comparison of general psychosocial functioning and the 4 subdomains showed that both immigrant groups showed functional improvement in the first 12 months after diagnosis, where the Dutch group did not . General psychosocial functioning and vocational/academic performance improved in second-generation immigrants, where social relationship improved in both immigrant groups. And lastly, self-care improved in first-generation immigrants. Analysis of between-group differences in psychosocial functioning at baseline and 12-months follow-up yielded no significant differences, controlling for age, income, years of education and ethnic density . --- | Predicting symptomatic and functional outcome at 12-months follow-up Level of symptomatic remission at 12-months was predicted by general psychosocial functioning at baseline and level of symptomatic Abbreviations: GEN1, first-generation immigrant; GEN2, second-generation immigrant. a χ 2 test statistic. remission at baseline . Both general psychosocial functioning and social performance at 12-months were predicted by general psychosocial functioning at baseline and annual income. Vocational/academic functioning at 12-months was predicted by general psychosocial functioning at baseline and negative symptoms at baseline . Self-care at 12-months was predicted by migration group membership, ethnic density and emotional distress at baseline . And lastly, disturbing behaviour was predicted by years of education, income and neurocognition . --- | Language-related assessment bias To investigate possible language-related assessment bias in our sample, standardized scores on the verbal learning and visual learning tasks were compared within the migration-subgroups . These analyses showed that verbal-and visual memory functioning deficits were identical within Dutch , second-generation immigrants and first-generation immigrants . --- | DISCUSSION Our primary aim was to examine differences in symptom expression, neurocognition and social cognition between Dutch, first-generation immigrants and second-generation immigrants with a first-episode psychosis . Levels of positive symptoms, excitement and emotional distress did not differ between the 3 groups at baseline nor at 12-months follow-up. Dutch patients had lower levels of negative symptoms than both immigrant groups at 12-months follow-up. On neurocognitive and social cognitive domains, Dutch performed better than second-generation immigrants, who in turn performed better than first-generation immigrants. Our secondary aim was to examine the level of symptomaticand functional differences within and between these groups. The Immigrant group membership overall did not appear to be a key predictor across outcome models. However, immigrant group membership was the strongest predictor of self-care at 12-months follow-up, supplemented by ethnic density and emotional distress. Compared to other first-episode studies, overall psychotic symptoms were moderate to low in this sample . But even though previous studies indicate that immigrants might have slightly more affective symptoms than non-immigrants , the present study could not replicate this finding. In contrast, result show that Dutch patients had lower levels of negative symptoms than both immigrant groups at 12-months follow-up. Overall, there do not appear to be any clear indicators that the core psychopathology of psychosis manifest differently in patients with different migration background . Second, neurocognitive and social cognitive functioning differentiate between the Dutch and immigrants, but also between first-and second-generation immigrants. A general pattern was observed of Dutch performing better than second-generation immigrants, who performed better than first-generation immigrants. However, interpretation of these differences is not straightforward. Primarily because cross-cultural assessment of cognitive functioning is a thoroughly complex issue in itself , but also because there are no previous first-episode studies on cognition on possible differences between patients with different migration backgrounds . Considering possible assessment bias, the direction of the observed general cognitive differences between groups suggests a prominent role for language bias, that is, the observed effect follows the same pattern as might be expected based on the level of mastery of the Dutch language across groups . To investigate this issue, our key verbal learning and visual learning task were compared within each of the ethnic groups. This comparison showed that verbal and visual memory problems were of identical size in all 3 groups. These findings suggest that the impact of assessment-language on cognitive scores in the present study is likely to be little , although measurement bias cannot be ruled out. A final post-hoc analyses showed that cognitive differences between groups were also not explained by differences in age or years of education or . Nevertheless, taking all the above into account, caution is required when interpreting or generalizing these findings because of heterogeneity and lack of a suitable theoretical framework in which to integrate them. Third, the 3 groups had similar levels of psychosocial functioning in the first year after intake. Since migration is considered a prominent risk factor for psychosis , it is surprising that migration-related differences in functional outcome of psychotic disorders have not been studied more extensively. Early UK studies on general functional outcome in samples with patients from varying migration backgrounds showed marginally better functional outcome in immigrants compared to non-immigrants ). More recent Dutch data showed no significant differences in psychosocial functioning between the 3 groups . The present results illustrate that shortterm functional outcome is not better or worse for immigrant patient compared to non-immigrants, neither in general levels of functioning, but also not in key subdomains like vocational and academic performance, relationships or self-care . In our exploratory analyses of demographic-, psychopathologicaland cognitive predictors of psychosocial functioning and symptomatic recovery at 12-months follow-up yielded several point of interest . First, 12 months is rather a short follow-up period. As a result from this, we found large predictive values for baseline functioning as predictor of future functioning and for baseline symptomatic remission as predictor of future symptomatic remission. Longitudinal follow-up of this sample will enable us to study how these associations develop over time and what baseline predictors will increase in value with extended follow-up periods. Second, although previous research indicates a central role for negative symptoms in functional change in FEP patients , the present data only replicated this association in the area of vocational/academic functioning. Third, higher income appears to be a predictor of poorer functional outcome across multiple domains in the present sample. Although counter-intuitive, this finding is in line a number of previous studies . Although a recent review concluded that there is not enough evidence to support the association between social class and psychosis , it has previously been hypothesized that the genetic predisposition for a high IQ may be associated with the genetic basis of schizophrenia . Fourth, in contrast to previous findings duration of untreated psychosis did not contribute to the prediction of outcome in the present sample . To a lesser degree, this was also the case for neurocognitive and social cognitive deficits , even though neurocognitive deficits at baseline did predict the level of disturbing behaviour at 12-months follow-up. Disturbing behaviour of patients with a psychotic disorder is a major public health concern, affecting patients and their environment . Previous research indicated several environmental ) and clinical dimensions and excitement ) that contributed to the manifestation of aggressive behaviour. Although our findings did not confirm the predictive value of excitement, our data support higher levels of baseline neurocognitive performance as predictor of less disturbing behaviour in FEP patients. And lastly, migration group membership and ethnic density generally did not appear to have a marked impact on outcome, except for the outcome domain "self-care." Although this finding might reflect that in the present study only the firstgeneration immigrant group showed improvement across the study period in this domain. Unfortunately there is no similar study to contrast these results and to examine whether or not this could be a relevant finding. This issue warrants further study. The absence of data on medication-and cannabis use at the time of the study should be considered as limitations when interpreting the findings. However, impact of both short-term anti-psychotic medication and/or cannabis use on the observed associations is likely to be small as well as heterogeneous. Another limitation is that language ability was not assessed. Even though our post-hoc analysis yielded no clear indicator of language effects on our cognitive data , masked effects of language skills on our data cannot be ruled out. And lastly, we did not asses cultural effects that impact general information processing styles that may have impacted our data ("analytic" vs "holistic"; eg, The major strength of this study is that, to our knowledge, it is the first study to assess differences between patients with different migration background in psychopathology, neurocognition, social cognition and both psychosocial as well as symptomatic outcome in 1 large FEP sample. Furthermore, our study is the first to explore the prospective impact of 6 key symptom dimensions across 3 groups from different migration background. The high representativeness of this early psychosis sample, that is, including all consecutive patients with a first-episode psychosis from 1 large urban area who completed baseline measures within 3 months after first contact, further adds to this strength. Overall, the present study shows that psychosis appears to manifest similarly across Dutch, first-and second-generation immigrants , where only neurocognitive, social cognitive performance, and to a lesser degree negative symptoms, appear to differentiate between these groups. Functional limitations over the first year after diagnosis also appear to be comparable. Nevertheless, the observed differences in functional and symptomatic outcome --- APPENDIX

The primary aim was to examine differences in baseline symptom expression, neurocognition, social cognition and psychosocial functioning between Dutch, first-generation immigrants and second-generation immigrants with a first-episode psychosis (FEP). The secondary aim was to examine functional and symptomatic change and between-group differences at 12-months follow-up. Associations between migration, baseline characteristics and outcome were explored. Methods: Forty-six Dutch, 56 second-generation-and 60 first-generation immigrant patients completed baseline measures for 6 symptom dimensions (positive symptoms, negative symptoms, neurocognitive functioning, social cognitive functioning, excitement and emotional distress) and 5 domains of psychosocial functioning (general functioning, work and study, relationships, self-care and disturbing behaviour). Functioning and psychotic symptoms were assessed at baseline and 12-months follow-up. ANCOVA and t tests were used to assess between-group differences. General linear models were used to explore within-group differences. Backward-regression was used to explore predictors of outcome. Results: Levels of positive symptoms, excitement and emotional distress did not differ between groups at baseline or follow-up. Dutch patients had lower levels of negative symptoms than both immigrant groups at follow-up. On neurocognition and social cognition, Dutch performed better than second-generation immigrants, who in turn performed better than first-generation immigrants. Psychosocial functioning across all domains at baseline and at 12-months followup was similar across groups. Baseline levels of general psychosocial functioning and income were the strongest predictors of outcome at follow-up. Conclusions: Psychosocial functioning and symptom profiles are comparable between Dutch, first-generation immigrant and second-generation immigrant FEP patients, excluding neurocognitive and social cognitive deficits. A range of baseline characteristics predicted outcome.

Introduction There is a widespread agreement among world leaders that food waste is a serious problem with far-reaching economic, environmental, and social consequences. By 2030, the United Nation aim for responsible consumption and production and wants the world to halve per capita global food waste at the retail and consumer levels and reduce food losses along production and supply chains, including postharvest losses . Most local governments in Malaysia spend 60 -70% of their annual budgets on sending food waste and other municipal solid waste to landfills. According to Jereme, Siwar, Begum, and Talib , Malaysia has an ample food surplus. The fact that the first question a Malaysian will ask a friend is "sudah makan?" which translates to "have you eaten?", demonstrates the importance of food in everyday life. Food shopping and eating habits in Malaysian households are influenced by Malaysia's unique cultural and geographical qualities, which distinguish the country from Western countries and play a role in Malaysian's cuisine. Traditional markets, mass-merchandising supermarkets, and retail stores are only some of the many types of foodpurchasing options available in Malaysia, which is a good example of how diverse and convenient these options can be. Despite the incredible variety of foods available, it is terrible that the community still maintains a wasteful attitude about food and that this waste has become a regular habit . It is found that Malaysians have generated 16,688 tons of food waste per day which is enough to feed 2.2 million people for three-time meals per day . --- Solid Waste Management and Public Cleansing Journal of Sustainability Science and Management Volume 18 Number 5, May 2023: 124-142 Cooperation forecasted that at the end of 2020, the total amount of food waste generated will be enough to fill 16 of Malaysia's Petronas Twin Towers which is 451.9 meters tall . According to Vermeulen et al. , achieving Sustainable Development Goals such as zero hunger and keeping climate change under 2°C requires not only greater food security among the poor or marginalised people but also a shift in wealthy people's consumption patterns toward greater sustainability . Household food waste accounts for a sizable portion of the global food waste problem, which has its roots in modern lifestyle choices, the speed with which industry has developed, the proliferation of ready-to-eat foods, and the prevalence of a consumerist mentality. People's emotional connection to food is likely to have changed due to the many changes in the socioeconomic and demographic composition of families, as well as in their eating and cooking habits and the types of foods they eat. Many people do not attach any emotional significance to food, so they throw it away without a second thought. The significance of preparing meals together as a family or eating together as a group has been lost to some people, and as a result, food is no longer used as a way to socialise with other people . Scholarly interest in the factors contributing to or causing widespread food waste in homes is rising. Researchers have examined demographic data, specifically age, income, and household count. The amount of food that is thrown out is influenced by environmental factors. Behavioural changes associated with increased food waste awareness are hypothesised. Relationships to food waste can be seen in factors including the way of life, shopping habits, emotional role, consumer values, and societal standards . Furthermore, as mentioned by Kowlesser , inadequate official support and a lack of available technical and financial resources further complicate efforts to establish a workable food waste management system. Due to a lack of knowledge about the negative health and environmental effects of waste, illegal dumping and burning are typical practices among households. Therefore, managing and eliminating food waste is a crucial aspect of food chain responsibility and sustainability programs. This study is relevant for a few reasons. The majority of food waste originates from homes. In addition to being the final link in the supply chain, households are an essential target for food waste reduction initiatives. However, according to Stancu et al. , evidence on why consumer-generated food waste occurs remains vague. There is a paucity of research concerning consumer-generated food waste, especially in the context of private households with most studies being carried out in the United States, United Kingdom, Finland, and Denmark . Despite the rise of studies on the subject, little is known about the underlying factors that encourage and impede food waste practices . Appropriate interventions to reduce household food waste require place-based and spatially sensitive analyses considering the particularities of local food and waste management systems and cultural norms about food. Previous studies have identified several factors that influence food waste in households. However, these factors may vary by geographical and sociocultural contexts. Thus, to fill the gap in the literature, this study explores food waste practices in Malaysian households, particularly among lower-middle-class families, with a specific focus on identifying and exploring the antecedents and barriers to food waste reduction. Using a qualitative approach, the research relies on semi-structured interviews with fifteen lower-middle-income Malaysian households. Researching the topic from an individual's point of view allows us to get closer to the particular scenario at hand while also considering the local context of food waste in homes. As a result of this research, ideally, policymakers and the government will better grasp the issue of household food waste and can implement some of the study's helpful recommendations, which are especially relevant in the context of Malaysian families. While the findings from this study are from the Malaysian perspective, the discussion and implications are of interest globally, especially in other developing countries where food waste is also considered a substantive issue. --- Literature Review The problem of food waste is complex and wide-ranging, with many studies having identified various antecedents of household food waste. Food waste takes place in families' daily routine behaviour and activities during shopping, cooking, storing, and eating that they are unaware is interconnected with food waste issues . These unacceptable and unrealisable behaviours will greatly impact the whole universe. Xue et al. have claimed that there was a rise in food leftover as individual income increased due to the affordability of purchasing more. Lowincome families tend to be more careful about spending because of less purchasing power. However, this statement regarding food waste is contradicted in low-income households. Studies by Porpino et al. found that food waste also happened in lower-income households due to inappropriate behaviour while food stocking, preparation, food consumption, and food storage. Meanwhile, a literature study found that there seems to be a lack of clear understanding between the household income and food waste relationship . --- Antecedents of Household Food Waste Few factors are identified for household food waste, including consumer behaviours, consumer perception and attitudes, consumer socio-demographic characteristics, household characteristics, food-related characteristics and policy and regulation . Larger households are found to waste more food , the same holds for higher-income households . According to Stancu et al. , consumers' report of food waste behaviour was significantly correlated with household size, income, and age. Lower amounts of food waste were associated with older consumers, fewer members in the household and lower income. Zainal and Hassan have examined several antecedents of food waste behaviour in a few works of literature and their findings varied. They include several situational characteristics that relate to the portion of food that the households threw away, one's intention, and psycho-social aspects such as cognitive factors and other additional determinants. For example, the awareness and knowledge of food waste as well as habits related to shopping and household planning. Consumer behaviour regarding food and waste is affected to a great extent by the level of knowledge and education one has on these issues. Education, improving awareness, enculturation and mass media significantly reduce food waste . Stancu et al. have examined how household food-related routines, skills and psycho-social factors are associated with household food waste behaviour. Findings suggest that food-related routines are the main drivers of food waste in addition to perceived behavioural control. Among the routines, the leftover reuse routines were the most important contributors to food waste but were closely followed by shopping routines. Prior literature supports the importance of household foodrelated routines in understanding food waste behaviour . Perceived behavioural control could also influence the food-related behaviours of consumers, especially food planning routines and shopping routines . In food waste related to household waste management , it has been Journal of Sustainability Science and Management Volume 18 Number 5, May 2023: 124-142 shown that attitude, perceived behavioural control, intention, moral obligation, selfidentity, action planning, and past recycling behaviour were significant predictors of household waste . During the COVID-19 pandemic, buyers' physical activities were restricted, and they had to stay home. The time spent online increased, and the food buying pattern shifted to more online purchasing than in the past. The study conducted by Lahath et al. advanced the knowledge of sustainable consumption with the findings on the increased social media usage, neuroticism, and impulse buying that eventually drove food waste during the COVID-19 pandemic. Sustainable Development Goals include no poverty, zero hunger, good health and well-being, responsible consumption and production and other urgent sustainable related issues. The sustainable accumulation of solid waste falls under the responsible consumption and production goals category. To achieve the mentioned sustainable goals, Malaysians must take considerable action in waste separation, mainly to reduce waste accumulation among households. --- Barriers to Minimising Food Waste A study done by Wakefield and Axon found that insufficient consumer knowledge, action and lack of appropriate waste facilities hindered the ability to carry out sustainable practices at the household level. Similarly, Nunkoo et al. suggested four major barriers to adopting food waste recycling in Mauritius. Space limitations, lack of awareness of food waste recycling, inadequate regulations and policy and lack of time/priority were identified as barriers faced by the households to recycling food waste. According to them, space constraint is believed to be the major barrier to minimising food waste, particularly for those who live in an apartment. On the other hand, a lack of awareness about food waste recycling occurred as many people have insufficient knowledge regarding recycling, composting, and disposing of food waste . Knowledge and information alone do not change behaviours . Appropriate information has been reported to promote increased awareness directly associated with reducing food waste . Most of the studies have supported that households' efforts to control food waste behaviours are nearly not possible because many households are lacking in terms of environmental awareness, households' environmental knowledge and government food waste reduction policy . Other research has shown that the wasteful behaviour of an individual is determined by factors related to current legislation or policy. South Korea is one of the countries that executed the policy to reduce food waste called "Pay as You Trash" . The enforcement of this policy had a vital effect on environmental concerns among citizens and reduced the total amount of Municipal Solid Waste . It is demanding to purchase certified plastic bags for waste disposal for every household. However, recycled bags can be disposed of for free . Through this policy, Seoul has successfully cut off its food waste from 3300 tons per day in 2012 to 3181 tons per day in 2014. To successfully implement this program, they have installed a Radio Frequency Identification bin to weigh the waste made by each household and assure that they will get their bill accordingly. Also, waste bag prices have increased by 30% since the beginning of 2016 . Japan's Food Waste Recycling Law is a policy that was introduced to minimise waste. Nevertheless, it only applies to the food industry at the moment. Extra hard work is immediately required to reduce and recycle food waste across all stages of the food supply chain, especially at the consumer level . Many consumers are having a problem with the misinterpretation of date labels as they experienced a lack of understanding and following the instruction to properly store as stated on the label . Exemption from responsibility occurs when many households give several reasons to ensure they are free from the accountability of producing and dealing with food waste . --- A Conceptual Framework Based on the research problem analysis and the literature review findings, a framework has been developed. Figure 1 is a conceptual model depicting the relationships between the causes of food waste and the barriers to implementing effective methods for reducing it. --- Research Methodology --- Participants and Sampling Procedures Participants across Malaysia were recruited and agreed to participate in this study. Recruitment of participants was supplemented using convenience and snowball sampling techniques to seek participants from lowermiddle income groups . Apart from that, the eligibility criteria for participant selection included having someone responsible for food decisions and familiar with food waste at the household level. The initial data collection phase involved four families, who were recruited with the help of a community leader, who then introduced the researcher to the families. All 15 families came from urban, suburban, and rural areas in Malaysia. Only women were chosen to be interviewed in the search for eligible participants. Women are believed to spend approximately 85 -90% of their time on household food preparation and cooking . Women tend to be more engaged with household activities such as grocery shopping and act as nutritional gatekeepers who typically control 72% of the food consumed by their children . It is also known that those with high incomes tend to buy more food than those with lower incomes. People from high-income societies have been identified as contributors to household food waste . Without a doubt, COVID-19 has impacted the welfare of Malaysian households unequally, pushing the existing inequalities to the forefront and risking major impacts on economic and social conditions. Therefore, based on the Household Income and Basic Amenities Survey Report 2019 from the Department of Statistics Malaysia, participants under the bottom 40% of income earners and middle 40% of income earners were selected to partake in this study. The B40 group has been categorised as the lowest household income group, whereby they are measured as a unit that earns a household income of less than MYR 4,850 per month and less than MYR 10,960 per month for M40. Participant characteristics are summarised in Table 1. --- Interview Procedure Semi-structured interview sessions were performed between November and December 2021 at the researcher's office or home. All questions were open-ended and formulated concerning the broad purpose of the study and the existing literature on the topic. The interview questions focused on the participants' general background, understanding of food waste, the causes of food waste, and the challenges they face in recycling food waste. Armed with the research objectives, questions were developed in such a way that it allowed participants to express opinions in their terms and words freely. As the interview progressed, probing questions were added whenever necessary . When additional interviews did not provide new information on the thematic concepts , the saturation point was reached with the 15 th interview. The interviews lasted 45 minutes on average and were tape-recorded and transcribed verbatim soon after. --- Data Analysis and Interpretation Interview transcripts were coded using the analytical data procedures of thematic analysis to identify categories underpinning households' beliefs and behaviours about food waste. First, transcripts were read and reread several times to have a broad understanding of the data and to identify any evident trends. This initial 'open' coding was refined as new insights emerged. Second, 'axial' coding was performed by connecting the category and its subcategories . Further, following Strauss and Corbin , 'selective' coding was used to show interlinkages between the core categories. Journal of Sustainability Science and Management Volume 18 Number 5, May 2023: 124-142 Throughout the analytic process, we adopted the constant comparison method . Unique and new instances in the data were compared to existing categories to develop an understanding of the core meanings. Participants expressed their views on food waste antecedents which included: overpreparing; overbuying; dietary transition ; and improper storage. The findings also led to the development of four themes that defined the barriers participants face to recycling food waste: inadequate regulations and policy; lack of time; lack of education and awareness about food wastage; and lack of appropriate facilities. --- Research Framework As outlined in Figure 2, the study was conducted using Qualitative Content Analysis which systematically explains the data collected through semi-structured interviews to answer the research questions. The findings were interpreted via a systematic classification process of coding and themes were identified. After a thorough coding of the analysed data, the findings of this study were analysed and compared to those of previous studies using the summative technique of QCA. --- Ensuring Rigor, Validity and Reliability in Qualitative Inquiry Following Merriam and Grenier , this study performed a review process through peer checking and examining to enhance the validity and reliability of the qualitative research. Segments of pertinent and useful data were identified with memos, then initial codes were attributed. Three researchers further read each other's memos and discussed their insights, comparing coding and themes before reaching a consensus on the delivery themes. They focused on the research questions and analysed the transcriptions using a line-by-line open coding procedure. Original data such as recordings and archival data, have been completely utilised during data analysis and presentation to ensure that interpretations of the data gathered were authentic. Thus, the validity of the qualitative data in this study was ensured through the use of multiple methods of data collection and the use of multiple researchers' checking to reduce researcher bias . Furthermore, personal identifiers were removed during transcription to maintain confidentiality, secrecy, and anonymity of participants' identities. A pseudonym was used, with special consideration given to the information obtained. The researchers referred to the participants as P1, P2, P3...P8 to protect the identities of the households involved and to avoid the possibility of pseudonyms being misinterpreted as real subjects. In qualitative research, ensuring credibility, dependability, transferability, and conformability aided in establishing trustworthiness. --- Results and Concluding Discussion --- Antecedents of Food Waste All these fifteen mothers reported having wasted leftovers in the week before the interview was conducted. When asked about the major causes of food waste, participants elaborated on several factors that mirrored the findings of the literature review. Surprisingly, they also discussed further aspects of these findings and raised interesting points. --- Overpreparing Families who value abundance on the table might translate the habit into enormous food waste. All participants claimed they preferred to present large servings on the table and ensure plenty of food for everyone. Given that women are mainly responsible for most chores and cooking, this study also observed that the participants chose to prepare from scratch, leading to over-preparation and creating more food waste. "Having plenty of food is important because I want to ensure that the food is enough for everyone. All meals are prepared from scratch and fresh products, especially when it comes to vegetables and seafood. My husband and I don't like processed food. However, I found it very difficult not to be over-prepared. Guess it's just a habit to have plenty of food on the table, even if they don't eat and are dumped out of sight." In the context of "eating properly", these comments further support the findings that demand for cooking a variety of meals from scratch and fresh products might cause overpreparation, a key antecedent of household food waste . When explaining food preparation, participants tend to justify the habit of overpreparing due to practicality and minimising inconvenience, helping them to save more time in the kitchen. These comments support the findings from Porpino et al. , as they identified that women in the low-income context in Brazil considered cooking in abundance to save time. --- "Yeah, nowadays we have busy lifestyles and demanding jobs, so we prefer convenience. I like to prepare a great quantity of food and can save my time from preparing another batch of meals even though I couldn't finish all of it, or else I would be the size of the house." Comfort food, in particular, was found to be stocked in abundance to be eaten as snacks between meals and to ensure psychological comfort. Due to snacking habits, prepared food was not consumed or even stored in the refrigerator because many families claimed they did not prefer to repurpose leftovers, presumably, generating more food waste from the households. Studies by Stancu et al. and Van Geffen et al. postulated that saving and eating leftovers can prevent food waste. Due to over-preparing, participants who experienced dissatisfaction with food freshness or prejudice against leftovers were deemed as promoting consumer food waste . Participant 11, from her experience, clarified that: "My children graze throughout the day enjoying a never-ending snack time. The only thing about snacking was that they sometimes skipped their meals, leaving prepared food uneaten. Also, I noticed that my children won't eat the leftovers even though I repurpose them the next day. Therefore, whether they eat or not, I won't keep my leftovers in the fridge and make sure I dispose of them before going to sleep." Although the desire not to waste good food or money was a considerable reason for some, so was the desire to be a good parent. The need to feel like a good provider and minimise the sense of guilt if they failed to satisfy personal and or cultural expectations was uttered by some of the participants and this perceived need was normally fulfilled by over-preparation of food. Individuals also appeared to be highly influenced by the desire to provide plenty of food, showing further evidence that food waste practices are associated with the role of the matriarch . Parents, most notably mothers, described the importance of providing abundant food for the family as a symbolic gesture of their abilities to protect and nurture them, even if the food goes straight to the bin. Thus, among participants who could be classified as "caring for the family", they appeared to be of paramount importance when identifying the antecedents behind current food waste practices: Having a sense of identity to provide ample food for the people is an important driver of individual behaviour to express who they are and would like to be . Therefore, echoing Evan's findings, we found that the desire to be good at providing abundant food for the family, associated with affection and abundance, was a strong antecedent of food waste among lower-middle-income Malaysian households. "I cook --- Overbuying Four participants confirmed that their habits of buying food in bulk without properly planning for grocery shopping for the coming week will have generated more food waste. Purchasing items that do not fit into their ordinary meals is why food is forgotten, spoilt, and discarded, which is positively related to underlying causes of surplus food. Others justify the habit of their excessive purchase due to the strict lockdown imposed by the Malaysian Government in March 2020. For many household food purchasers, the desire for every spot in the pantry to be filled with food shows that people are often misled by their surroundings, which apparently will lead to overbuying and food not being used before it goes bad. From the psychology of food waste, this habit portrays that they dislike spotting any white spaces in their kitchen, and as a consequence, they are driven to overbuy. According to them, the products that usually be bought in abundance are canned food, cookies, bread, and sauces. --- "Sometimes when I am in the supermarket, I will buy without the real need for it since I do not plan for my grocery. I even forgot that I bought that --- "I just love to see my cabinet filled with canned food and cookies. I'm worried about not eating. Knowing that there is food in my cabinets will give me a pleasant feeling. And I don't like to see empty spaces because having plenty of food is important for me, especially when someone comes to your home unexpectedly. At least you can find something to cook and serve them. That's my way." "I constantly buy bread in bulk when I do grocery shopping but most of the time, there is always a bunch of them that remains uneaten. Canned food and sauces are my must-buy items when I go grocery shopping. I feel better when I have a ton of food in my pantry." Other empirical evidence referred to the tendency to buy a product with discounts. This was supported by Graham-Rowe et al. , as they reported that household food purchasers blamed supermarkets for palming off their waste to consumers through special offers, such as "two for the price of one" or prepacked foods, typically fruits and vegetables. The following quotation exemplifies this tendency: "If we find there are 'Buy-One-Get-One-Free' or 'Buy-Two-Get-One-Free 'deals, we end up buying although we still have it at home. Mostly vegetables and fruits are all pre-packed and oftentimes you can't tell how fresh they are. I think this is how supermarkets use the trick to get rid of their waste." These comments further support findings that the habit of overbuying, including buying in bulk and stocking food at home, is responsible for generating more food waste . Relatedly, Stuart has argued that having food to spare, even for the food that is ever likely to be needed, can sometimes be reassuring. Several studies described that the increased food wastage among the lower income households might result from higher expenditures, with the tendency to patronise warehouses for cheaper bulk purchases . Inexpensive goods are often viewed as low-quality food, such as having shorter shelf life and poor nutritional value, impeding consumers from their disposal syndrome . --- Dietary Transition Interestingly, participants 4, 7 and 13 experienced a rapid transition in dietary patterns, accounting for a much greater proportion of perishable foods. The changing consumption patterns will constantly generate more food waste as people eat less starchy food and take more fresh fruits, vegetables, fish, meat, and dairy products. Even some reported having adults with diabetes in families that must adhere to dietary restrictions. As mentioned by one of the participants: --- "My husband was diagnosed with diabetes and a non-diabetic spouse Journal of Sustainability Science and Management Volume 18 Number 5, May 2023: 124-142 like me needs to learn new diet habits. Since then, he only prefers fruits and vegetables, but I find it very difficult to keep them fresh. Most of the time, they went bad in refrigerators." These statements indicate that stockpiling perishable foods is more vulnerable and more likely to be wasted according to their shorter shelf life. In addition, a similar observation was reported by Parfitt et al. and Porpino et al. , whereby higher rates of food waste are due to quality diets containing unprocessed foods, including fresh fruits and vegetables. --- Improper Storage Participants 2, 6, 8, 11, and 12 reported that food spoilage at the household level occurred due to improper storage. This finding is in line with few studies as they claimed that proper food storage could decelerate the ageing process and reduce food waste . They experienced a problematic relationship with leftovers as the food was stored for too long in the refrigerator, lost its quality and ended up in the bin. Participant 6 stated she was so forgetful, not remembering that she had food in there until the cleaning day and the leftovers were finally thrown away after a long period. Besides, high-risk foods, especially those in packages, cans and jars, should be stored and handled correctly. Interestingly, some participants faced difficulty, especially during festive seasons or when expecting guests, as their refrigerators were always packed with these foods and there was no space left for a small container to be stored. According to participant 12: "We experienced inappropriate storage in the fridge, especially during Hari Raya. For this event, we have many guests coming to our house, so we tend to stockpile food on a large scale. We ended up having many opened canned and tinned food in the fridge. At the end of the day, if I am not uncertain of the use-by-date, I just throw it out." The results demonstrated that due to poor storage, food began deteriorating, leading to significant physical and value losses. Not all people prefer the taste of changing or drying food, and this liking caused more food to be discarded. Knowledge of proper storage has proved to help reduce food waste by up to 20% . --- Barriers Towards Sustainable Food Waste Practices The thematic analysis found four barriers towards sustainable food waste practices amongst the households and details are as follows: --- Inadequate Regulations and Policy All participants unanimously agreed that the symptoms of the environmental crisis today were due to the paucity of regulatory frameworks and policy attention for managing food waste in Malaysia. Some of the interpretive codes used to indicate their views were "government do not do enough", "no strict schemes for food waste management", and "not everyone access to food waste bins". Addressing this barrier will likely improve food waste practices . For example, the government imposes a penalty and fee for households not complying with regulatory provisions or providing subsidies if they handle food waste properly. Well-defined regulations and policies seem to be a more effective apparatus to combat household food waste generation and the findings are similar to prior research of Schanes et al. and Nunkoo et al. . Some of the responses are: This comment reflects the findings of Graham-Rowe et al. and Nunkoo et al. , who found that lack of time was among the barriers to not adopting household food waste minimisation behaviours. "I think --- Lack of Education and Awareness about Food Wastage Participants portrayed a lack of education and awareness on food waste composting, not knowing sustainable ways to dispose of food waste. "Food waste was not a big problem", "never thought about it", "backyard smells of rotting food", and "not aware of other ways to compost" were interpretative codes mentioned by four participants to explain their lack of awareness on how to carry out sustainable food waste practices confidently. One participant noted that a composting method she adopted a few months ago seemed ineffective, indicating a lack of education and awareness of the importance of the issue and its viable solutions: These statements signify a crucial need for disseminating relevant knowledge and information regarding sustainable food waste practices, especially at the household level. A general lack of education and awareness of food waste has been documented in prior research . It has been claimed that this lack of education and awareness may be a consequence of why household food waste is being discarded a bit at a time. --- Lack of Appropriate Facilities A third apparent reason that hindered their ability to carry out a more sustainable approach was the lack of appropriate facilities. "No recycling or compost bins for wastage", "food composting systems are expensive "and "no source separation pickups" were the codes mentioned by four participants to describe the lack of appropriate facilities for food waste recycling. Some of the responses were: "I currently live in a city apartment, and I do not have any compost bins for wastage." "If the municipality can provide source separation pickups, I think it would be much easier for me to recycle food waste and I believe it would be beneficial for all of us." Regarding financial concerns, some participants stated that food composting systems are not cheap to maintain, preventing them from recycling food waste. Thus, Abdelradi has concluded that it is important for the participants to have easy access to food recycling to motivate them to manage food waste more sustainably. These comments indicate that several participants responded negatively to the lack of facilities available to carry out sustainable food waste practices. The finding supports previous research of Abdelradi , Nunkoo et al. and Wakefield and Axon . --- Implications of the Research Our study provides valuable implications for addressing the problem of food waste after explaining the barriers and causes of this trend. To this end, it will be necessary for consumers, companies, and institutions to work together, each playing to their strengths. The following is a list of several policy instruments and interventions that may prove to help reduce food waste at the household level: The results can be used to develop subjective norms campaigns that emphasise individuals' tendency to conform to the acts or opinions of their peers. According to a recent study by Wunder et al. , advertisements that provide information about the behaviour of others have proven to be effective in motivating individuals to reduce food waste. A targeted audience should be the focus of educational programs to enhance consumers' skills and understanding of food provisioning, cooking, and storage. 'Gerobok Rezeki' is among the charitable food drive that many mosques can adopt and many prestigious educational institutions. The community can reduce food waste thanks to this initiative. The findings of this study suggest that the secondary shelf life indications policy in Malaysia for consumer products can be significantly expanded or even eliminated. For instance, the extension of the labelled SSL based on its objective assessment would add value to the packaged food product without modifying the ingredients, formulation, or production process in any way. This innovation may increase competitiveness, causing consumers to choose the product with a longer shelf life over similar products with a shorter shelf life after opening. The end user could benefit from extending the food's shelf life after the initial opening, with significant reductions in domestic food waste, reduced household stock turnover, and consequential cost savings. Through the objective evaluation of SSL and its effective communication to the end user, this study can contribute to reducing domestic food waste and the overall sustainability of food chains. Food waste is also indirectly related to the energy resources used in producing fertilisers and other inputs and distribution, such as the energy used in storing and transporting food. Not only is there a waste of energy when food is thrown away, but there is also a waste of the water used to create the food. The current study by Some et al. have found that reducing food waste reduces energy use/demand , water use/demand and land use/demand for food production. Thus, the abovementioned mitigation strategies not only have synergies with the energy-saving goal but are also closely linked with awareness and educational programs , technological solutions/innovation , much broader innovative policy designs going beyond market incentives, and the participation of numerous social actors . At the level of 17 SDGs, it was evident from the findings that household food waste plans and programs had an impact on the achievement of SDGs, to varying degrees, with the greatest impact appearing in goals related to improving the quality of life and health in cities, as well as addressing climate change, enhancing life on earth, and fostering partnerships. --- Limitations and Future Research The research findings are too general, highlighting Malaysia's lower-middle-income households in comparing food waste. Little is known about the determinants of wasted food in the lower-middle income context. Most published papers consider food waste part of the Municipal solid waste 's responsibility. Therefore, searching for articles regarding food waste statistics in Malaysia is difficult. This study should be conducted in more diverse settings, such as income segments, specific states, and regions. However, due to the context-specific nature of food waste, our findings may be limited in their applicability to other countries. Future researchers can use subjective research methodologies to investigate household food waste in other countries to ensure that location-based characteristics are considered. Insights gained from such studies may help to advance our theoretical understanding of the social and geographical context of household food waste. Besides, the subjectivities inherent in qualitative research, as opposed to quantitative approaches, imply that the results may have been influenced by our personal biases, values, and prior knowledge of the existing literature. Therefore, other researchers must conduct similar studies in Malaysia to validate our themes and findings. Indeed, not all the intriguing issues could be covered in this study due to time and space constraints. To better understand home food waste and efficient management techniques for food waste reduction, particularly in Malaysia, future research may consider employing a mixed approach integrating qualitative and quantitative methodologies with longitudinal data collection. The fact that just 15 family food providers participated in the interviews for this study may also be a drawback. However, in terms of the sample size of interviewees, earlier research chose comparable or even much smaller numbers of the sample than the present study . Future research should increase the sample size to include a larger spectrum of Malaysian household perspectives. Many works of literature focus more on gaining knowledge about the issue than on coming up with remedies. Therefore, more studies should look for ways to put novel theories and interventions that might cut down on family food waste to the test. According to the studies analysed, consumer food waste is an interdisciplinary topic, and interventions should be systemically combined and created with various consumer groups as targets. Future research is advised to determine the expertise and partnerships required to deliver effective interventions. Moreover, researchers can evaluate the added value of involving consumers as code signers of interventions and the role of other food value chain stakeholders in encouraging consumer food waste reductions. As our study chose to focus on other elements due to time and space constraints, we acknowledge that these recommendations for future research are important and will greatly enhance the value of our work. --- Conclusions The study presents empirical findings of four antecedents and four barriers in a lower-middle income context which fulfils our objectives and contributes to previous consumer behaviour studies on food waste, particularly in Malaysia. This is not surprising, given that food waste is a real problem faced by lower-middle income families, and hence this needed to be supplemented by educating them on sustainable food waste practices. It is believed that a minor change in the individual behaviour of this segment will have a considerable impact on society at large.

Given the significant amount of food waste generated by households, reducing household food waste is critical to mitigating overall food waste and providing multifaceted benefits for humans and the environment. This study attempts to identify antecedents of food waste among lower-middle-class families in the Malaysian household setting and their barriers to sustainable food waste practices. Fifteen individuals from lower-middleclass Malaysian households were selected by convenience and snowball sampling and were interviewed using semi-structured questions. Four categories of food waste antecedents were identified (over-preparing, over-buying, dietary transition, and improper storage). The findings also led to the development of four themes that defined the barriers participants faced to minimising food waste (inadequate regulations and policy, lack of time, lack of education and awareness on food wastage, and lack of appropriate facilities). The findings from this study have important sociocultural implications for future studies, and they also add to our current understanding and application of how to reduce food waste in Malaysian households. More study is needed to find ways to test new ideas and interventions that could reduce household food waste, especially in Malaysia.

Introduction "A time of change" has become a familiar refrain in discourse concerning higher education. In April 2009 the Association of American Colleges and Universities asked participants in its conference to consider what is at stake in a time of "increased splintering of roles, contingency of status, and workload demand, and what faculty and institutions are doing to creatively and thoughtfully respond in the face of change and conflict" . A February 2010 report on the higher education workforce by the Higher Education Funding Council for England poses the question: "How can the sector become more flexible at a time of change while maximising the talent and commitment of its people?" . The report identifies technology advances as a major aspect of the context in which the sector operates; it is argued that advancing technologies and technology-based services will change public experiences and expectations when it comes to accessing and sharing knowledge. Higher education institutions will need to respond by providing more online learning, online content and more effective tools to find and use this content. The report also recognizes the continuing need for updated skills and ICT capacity. Institutions are bound to be considering how they can respond to these challenges. Conole draws attention to further emergent themes such as user generation of content and new practices of social viewing and content sharing. This paper will consider how universities should adapt to the new external conditions which have an impact on teaching and other activity within the academy, and in particular, advancements in technology such as social media, online social networking and mobile technologies. These are popular everyday tools and services that are also potential or de facto resources for education. They enable not only online learning but also offline -through digital resources such as e-books downloaded to mobile devices and accessed at the learner's convenience. Their widespread adoption means that mobile devices, and the social networks and resources they give access to, are a significant part of the grain of daily life . The findings of a survey of US college students, faculty and IT staff highlight that the technologies students use in their personal lives, such as mobile devices, blogs and podcasts, are largely absent from the classroom. Indeed, those involved in teaching have long argued that a new generation of technology-savvy students is entering higher education, bringing with it the need for a different approach to the use of digital tools . Research by Jones et al. and others demonstrates that students in advanced industrial countries are far from homogenous in their response to the new technologies; nonetheless it is clear that personal technologies are part of their social and learning landscape. Furthermore, we can expect that mature learners will keep returning to study to update their skills, for career advancement, or to learn for interest and enjoyment, bringing with them different sets of experiences and expectations with regard to the use of social and mobile technologies that they may have encountered as educational tools in the workplace. Increasingly, changes we notice in the use of technology in daily life may also be observed at work within the walls of the academy -physical walls or virtual. They are breaking down traditional barriers separating academic research from teaching, work-based learning and informal learning. Academic research requires keeping up with technological advancements and social media dissemination channels, even if technology is not the research focus. However in this paper, we are particularly concerned with those who are responsible for curriculum design and teaching delivery. The paper outlines a particular position with regard to faculty development, arguing that faculty engagement should go beyond technology adoption in their teaching to adoption in their own professional learning. Against the background of multiple opportunities for educational and professional development at The Open University, three specific initiatives relating to mobile learning are discussed: a Mobile Learning Guide, a set of active case studies in the form of 'Mobile Experiences', and a Mobile Learning Festival. Finally, a proposal is made regarding how the higher education workforce needs to adapt to the conditions created by a world which is fast becoming saturated with personal and social technologies capable of supporting teaching and learning. --- Position Statement Higher education institutions are currently challenged to look for innovative ways to develop their faculty, particularly in light of new economic realities that put pressure on resources . The challenge is to find cost-effective yet engaging solutions to the intractable problem of getting faculty to take seriously their own professional development with regard to new technologies for teaching and learning. Mclean, Cilliers & Van Wyk express a typical perspective on this issue: "If senior faculty administrators pay only lip service to faculty development, academic staff will perceive little need to participate and will spend their time where they derive most personal benefit" . This perspective reflects the widespread view that fundamentally, academic staff do not wish to participate in professional development, as they do not associate it with sufficient personal benefit. They will only engage if compelled to do so. This is congruent with the experience of many departments tasked with professional development of academic staff, even if many such units have found creative ways of tackling this problem through formation and animation of professional learning communities on campus or in virtual space. The key issue to highlight here is that of focus. While it is reasonable to claim that a major function of faculty development should be about "making teachers aware of aligning their teaching practice with the needs of students" , in higher education the needs of students may be perceived as relatively remote from the needs of faculty. To break this stalemate, to overcome this attitudinal barrier, a focus on personal, social and work-related use of personal technologies by academic staff offers an attractive alternative as a starting point. In her efforts to engage faculty in the adoption of distance learning, Powell uses the tactic of putting each faculty member in the position of online student, by running online workshops that give them some direct experience of online learning. A similar approach can be developed with regard to mobile learning. Fisher, Higgins, & Loveless found that little research had focused on how teachers learn with digital technologies, but rather there was research on how they learn about technologies, or how they use them to teach. Interest should now therefore be directed towards the possibility of higher education faculty learning with personal and social digital technologies. Furthermore, it is argued in this paper that learning with mobile technologies should go beyond hands-on experience, to the appropriation of the technologies for longer-term personal and professional development. In the process of learning with these technologies, attention might also be directed towards learning about the technologies, and reflection on their use for teaching and learning. --- Faculty Development Evolution Traditional and more innovative ways of providing faculty "training" in technology were discussed a decade ago by Backer , who even then remarked that for a public institution with limited funds, providing training is a difficult undertaking. During the past decade, the idea of training has morphed into 'development', which can be understood as an ongoing process concerned with changing attitudes and behaviours and preparing for the future. Development makes better use of the institution's human potential and places more personal responsibility in the hands of the workforce. Yet the responsibility still has to be shared, as faculty cannot do without some form of formal or informal support, and that may include "training". Burnett & Meadmore argued in favour of localized professional development, provided by colleagues with whom rapport has been established, since this offers a more sustainable form of support than centrally organized seminars and workshops. A localized approach makes connections with the pedagogical and disciplinary context in which teaching and learning takes place. In a similar vein, Friel et al. give evidence for the effectiveness of a "collaborative training team" approach whereby technology training is placed into a pedagogical context by means of pedagogical dialogue to complement technology skill attainment; their approach also involved IT representatives providing one-on-one faculty support between training sessions to allow for development of personal technology skills among faculty, and a hotline for immediate problem solving. Formal development and training may be supplemented or at times replaced by opportunities that are more informal. For example Anderson recounts the positive experiences of a group of staff in tertiary education who participated in informal professional practice groups in order to foster their professional learning and reduce isolation; groups comprising both academic and allied staff met in an informal setting, with the aim of learning by sharing ideas and experience. This type of work-based learning has previously been advocated by Mumford in the form of action learning sets which encourage an informal yet structured approach to learning from experience. The group approach can be taken to another level by developing a model of a faculty professional learning community or FLC ; such communities are largely informal, and they typically include more emphasis on the social and enjoyment aspects of learning. All the above approaches embrace peer learning from experience: collectively reflecting on a workrelated experience, or going through experiential learning together in a community or group. Considering faculty development for the future, Brooks observes that as technological advancements rapidly evolve, and as expectations to use technologies increase, faculty members need timely assistance when faced with technology-related problems. Short-term problemsolving is needed as well as support in long-term development. The sections which follow offer a review and reflection on opportunities for educational and professional development around mobile technologies in various institutions of higher education, including The Open University, UK. --- Faculty Development for Advancements in Mobile Technology Strategies for engaging faculty to consider how they might use mobile technologies to rethink their teaching range from those that take a whole institution or community approach to those that are concerned with transforming particular teaching programmes or how individual faculty can change their practices. An institution's primary mode of operation , its funding model , as well as its physical configuration , may also be factors in preferred styles of engagement. Institutional strategies include evaluating how faculty respond to the impact of mobile devices being distributed to large cohorts of students. Such is the case of Abilene Christian University where in 2008 all new students received an iPhone or iPod Touch and two generations of internal Mobile Learning Fellow projects have been established to study aspects of the experience. The claimed outcome is a transformation of faculty into "teaching-experimenters" and the development of a culture of innovation in the institution . A community focused approach is exemplified by Wright State University which established a learning community to help faculty implement mobile learning strategies in their learning environments during the course of a university-wide mobile learning initiative, concentrating on podcasting and digital storytelling. The goal was to enable faculty to gain proficiency in the use of technology for teaching and learning by utilizing a range of new tools to create learning resources as well as discovering existing ones. Seo et al. confirm that podcasting as a content delivery strategy has been instrumental in shaping new mobile learning communities in both traditional classrooms and in distance education. Their survey of a sample of US universities reveals that about a third have formal podcasting initiatives or training programs in place, and that these are more likely to be provided by larger, public universities rather than smaller, private ones. The authors argue that continuous administrative support and research efforts are needed in fostering podcast communities in higher education. As emerging educational technologies stimulate the formation of new communities, they are also increasingly shaping learning and development experiences that are more individualized. Mobile learning epitomizes this tension or challenge: mobile devices are uniquely personal tools as well as having notable capability to support intense and ubiquitous cooperative learning, social interaction and sharing. Their personal nature means that for example they are well suited to play the role of a personal 'mentor', assisting with meta-learning, such as ways of studying and remembering ideas, or providing long-term guidance on developing skills . The mobile device therefore acts like an experienced mentor, but it is perceived as a novel tool. An interesting analogy can be made with the idea of "reverse mentoring" put forward by Diaz et al. , whereby newer, "more technologically savvy" faculty members can assist senior faculty with new pedagogical approaches and delivery models, emerging technologies and tools. Combining personal technology use with a community dimension is another model . For example, Lefoe et al.'s project aimed to engage faculty, who were teacher educators, with personal use of mobile technology for six months prior to implementation in their teaching. This was done through an action learning approach that included learning activities addressing theoretical underpinnings and technology skills as well as opportunities for reflection, in a community of practice setting. For institutions offering mainly distance education, there is a primary focus on learner experience and it is considered important to ensure that students benefit from mobile delivery and interaction without relying on the informal peer and instructor support that is available in a campus setting. For instance in the Canadian context, Athabasca University has made great efforts to ensure content optimization for mobile delivery, including specific resources to create a mobile library. The university has also established mobile provision for particular target groups such as students requiring practice in English or French as a Second Language, and Workplace English . In these types of institution, and in other universities offering some distance learning provision, faculty development must focus on the implications of mobile learning for the design of distance teaching materials and student support, as well as consideration of research findings from studies of evolving learner practices with mobile technologies . The next section presents faculty development at The Open University, UK, with particular reference to mobile learning. --- Educational and Professional Development at The Open University The Open University has a firm commitment to offering both problem-solving and ongoing educational professional development opportunities to its large number of academic and academic-related staff, including development related to the use of new technologies for distance education. Table 1 exemplifies the offerings that have been developed in recent years. This represents a considerable array of opportunities to learn about, and to obtain support in relation to, new technologies, with many of the study materials, resources and events relating specifically to personal and social technologies and services. Some would argue that those who participate in these events and make use of the materials and resources might then need to work hard to integrate the knowledge gleaned from such an extensive "buffet" of diverse offerings . The diversity is partly a reflection of the fast pace of innovation in the university, resulting in online offerings that are also novel ways of experiencing educational and professional development. Integration can be achieved through personal development plans and an IT User reference framework which specifies a range of areas of competence for individuals using ICT in their role. An IT Helpdesk for any immediate problems with technology is also accessible by phone, SMS from a web page, and by email. --- Events • an annual conference with a strong focus on teaching and learning with new technologies In 2008 the university began working more intensively on a mobile learning strategy with a number of accompanying actions including the development of mobile access to the Virtual Learning Environment and surveys of students who were accessing the university's study resources via their mobile devices, to ask their opinions and ascertain their needs. A Mobile Learning Guide was also authored in 2009 by the university's Institute of Educational Technology, intended primarily for academic staff and module teams, to provide an introduction to mobile learning with some advice on implementation. The Guide was distributed widely in the university and an evaluation was undertaken to find out how the Guide had been received as well as faculty views on mobile learning and their own development in relation to it. The findings would guide future faculty development in this area. --- Seeking new directions: evaluation of the Mobile Learning Guide The Mobile Learning Guide is an attractively presented, A4 size, 20-page printed booklet explaining mobile learning, why it is important, what it is good for, how to design for mobile learning and how to evaluate it. The booklet also includes several brief case studies of early mobile learning implementations in various parts of the university, and gives contacts and some resources. The Guide is part of a series of Learning and Teaching Guides produced in the Institute of Educational Technology. The Guide was evaluated in 2010 by a researcher who had not been involved with its creation or distribution . The overall purpose of the evaluation was to gather feedback from Open University staff who had received a copy of the Guide. The evaluation sought to establish: In relation to the Guide • which parts of the Guide the interviewees found useful • whether they engaged with suggestions designed to stimulate thinking about mobile learning In relation to their courses • whether they had introduced any mobile learning components to their courses • which aspects of mobile learning were relevant to their courses --- In relation to developing mobile learning provision • what they would need in order to develop their own mobile learning provision • who should provide help or advice To obtain this information, 24 course chairs and course managers, comprising three per faculty were randomly selected from those who had been sent the Guide at the time of distribution. Fifteen interviews were carried out in person at the Walton Hall campus, 7 interviews were conducted by telephone, and 2 were completed over email. Although interviewees were not required to have read the Guide ahead of the interview, some requested a fresh copy as an aide memoire. It turned out that the Guide had not been not widely read by the recipients in the sample. Some of the reasons that interviewees gave for this included the perception that neither reading the Guide nor mobile learning constituted a core activity for course leaders; that a number of different Guides had arrived at once and presented too much extra curricular reading in one go; and that course teams were already stretched to capacity and could not accommodate any extra work. Furthermore, although the transition from print-based to online teaching and learning had been realized across most of the university, there were still some course teams for whom this transition remained a more pressing concern than moving on to the introduction of mobile learning. There was a range of reactions to the idea of introducing mobile learning within Open University courses; some enthusiastic, some neutral and some sceptical or negative. Where interviewees expressed concerns about the value or usefulness of mobile learning, their comments indicate that these concerns may have resulted from misconceptions about the way that mobile technology might be integrated into course production, or what constituted mobile learning. Podcast content was perceived to be relevant to their courses by almost all of the interviewees, but they did not seem to connect this with mobile learning. In general, there was less enthusiasm for the use of mobile technologies for 'context specific learning', which may reflect the fact that the courses the interviewees were responsible for involve little or no fieldwork, or perhaps the interviewees' lack of personal experience of contextualised learning. Interviewees were asked what they thought they would need in terms of support to develop future mobile learning provision, with a number of suggested options, as shown in Figure 1. Case studies and one-on-one help/advice were the top choices, with a formal course being the least preferred option. Interestingly, responses to another question reveal that only 30% of interviewees thought that the case studies in the Guide were useful; the reasons for this remain known, and could relate to the format of the case studies, their relevance, content, or the fact that they were placed at the end of the Guide. Interviewees were also invited to make any additional comments. In these additional comments, there were signs of scepticism and anxiety: --- Q7. What "Mobile technologies are likely to have a fundamental impact on the way we learn, but the traditional values of education need to be preserved." "I'm concerned that 'bite-size' forms of communication are of limited use to teaching and learning." "A lot of our courses are text-heavy and it's not clear how this would translate to mobile learning." "There are massive cost implications for redesigning courses." "I'm very aware of the potential dangers of mobile devices in [health and social care] from the perspective of confidentiality and ethical issues. What kind of future is envisaged?" "There is also a concern that people who don't want to learn in this way could be disadvantaged." "When you explain mobile learning to me, it makes perfect sense, but I suppose that the devil is in the detail." There was also evidence of shifting points of view: "In general, I don't feel well informed about mobile technologies, and I'm too busy to find the time to do something I perceive as peripheral….That said, we are running a photo competition [in subject area] using Flickr, and this could be carried out completely on mobile devices." "Our courses are very much based in reflective practice and gathering evidence, so I can see how mobile devices could be useful for this. We as course leaders need to overcome our fear of new technologies, and this involves having the time to spend on these kinds of areas." "It's not always appropriate to use mobiles…That said, there is lots of potential for the use of this kind of device in science… One technology course, for example, uses a mobile device which takes all kinds of readings. The relevance of this for field work is obvious." The evaluation concluded that, although there was an encouraging level of interest in mobile learning, and most of those interviewed could see the relevance of mobile learning to their courses when presented with more detail, nonetheless important issues included the amount of time and effort course teams felt able to invest in learning activities which they considered to be peripheral to the delivery of their courses. In some cases, scepticism about the use of mobile technologies in delivering Open University courses seemed to be based on misunderstandings about the possible role of such technologies . The evaluation was a chance to reflect on our mobile learning strategy and the opportunities for faculty to gain knowledge and experience with mobile technologies for teaching and learning. At the same time, it was becoming clear that mobile technologies were rapidly becoming an important way to access social networks, which can be sources of support. Faculty also needed to understand that students would soon be accessing the university's Virtual Learning Environment via their mobile phones and tablet computers. We would therefore need to create opportunities for faculty to experience learning with these technologies, so that they might more fully assess the potential and explore some of the constraints. --- Moving on: Mobile Experiences and Community Building The interviewees had expressed a preference for case studies and one-on-one support. These options can be difficult to provide without significant resourcing. Case studies can also be time-consuming to produce; and there is a risk that people will request case studies but subsequently will not read them, so the presentation of the case studies must also be considered carefully. We wanted to come up with an innovative case study format, and we also looked for a way to give faculty access to individuals who had valuable experiences to share, in an environment where they could ask plenty of questions and get hands-on experience with mobile and social technologies. First, we developed a collection of new professional development resources in an innovative format, as a set of ten Mobile Learning Experiences. These cover increasingly popular activities on mobile phones, such as: • sharing photos, videos and documents • reading, editing and annotating e-texts • doing tests and quizzes • accessing information on the move • location-based access and sharing Each 'experience' is a description of something that can be done quite quickly by an individual at any time, on their own or with others, using their own mobile phone . The main purpose is to give hands-on personal experience of using a mobile phone to do something that individuals might want to do. For example, one case study describes how an OU-produced mobile app is used as a means of engaging current and prospective students in an interactive activity on human evolution. It is also a way to introduce what students already do, or might want to do, with their phones in the course of their studies with The Open University . We include information on how each activity is relevant to OU study or how it might promote OU study. Cost issues are considered, as this had previously emerged as a concern among course teams wishing to take advantage of some aspects of mobile learning. Second, we planned a new event. The annual 'Learn About' fair already provided a good model of a popular event where participants can spend concentrated time getting to know different technologies and the people who can provide them with further information and advice. It was decided to organize a Mobile Learning Winter Festival, which was held in January 2011. Over a two-day period, participants could spend as much or as little time as they wanted, trying out various mobile applications and services, and talking to more knowledgeable others. The Festival was organized around a number of themes, with a strong focus on the needs of academic staff and course production. The Mobile Connections website , which provides resources and is a gateway to community, was also launched and publicized at this event. Feedback from 48 optional evaluation forms filled in by participants in the Festival indicates that the event was very successful. There was particular interest in e-books, the iPad, the mobile VLE, iSpot and applications in language learning. The value of the event was often expressed in terms of hands on use of mobile devices and being able to talk to people. Participants remarked that students are asking about, and expecting to engage with, mobile learning. Following this event, colleagues from two different parts of the university have approached the Institute of Educational Technology with requests to provide them with additional opportunities to consider mobile learning, in the form of more targeted professional development for their academic staff. Their requirements have focused on individual and collaborative mobile learning activities that could be tried out by groups of academic staff, covering existing proven applications of mobile learning and some experiences with innovations that are already on the horizon. This will enable them to consider the feasibility of mobile learning in their disciplines and to debate its added value. --- Discussion Based on our work at The Open University in introducing mobile learning to academic and other staff involved in the production and presentation of distance education courses, we have previously argued that a major barrier to the uptake and integration of mobile technologies in teaching is the lack of personal experience of mobile device use for learning on the part of those involved. We previously reported our attempt to address this lack of hands-on experience by running a project to introduce a group of academics and other staff to the use of smartphones to support their own learning . Whilst this attempt created an opportunity that was appreciated by the participants, on reflection it did not create the conditions for personal conviction, since a particular smartphone and a specific use agenda had been imposed. The professional learning community approach adopted by that project has met with success elsewhere , but it requires relatively high levels of time investment and a commitment to change. Whilst not rejecting evidence that a community of peers is important in helping faculty take steps to investigate and adopt new technologies, it seems to be a necessary but not sufficient condition for generating personal conviction. The degree of freedom that faculty largely enjoy with regard to the ability to determine the approach, content and method in their teaching and research programmes is in contrast, and ultimately in conflict, with imposed uses of technology that are not born of personal conviction as to their validity and usefulness. In our Mobile Experiences, we have tried to cover concrete yet generic activities such as sharing photos and annotating texts, to appeal to a wide audience; they are simultaneously practical activities carried out on the academic's own mobile device. In the Mobile Learning Festival, there was ample opportunity to have quality one-on-one conversations and make arrangements for follow-up meetings and support. These elements -concrete activities, personal devices, quality discussion and good support -have emerged as important ingredients in the process of exposing faculty to the potential of mobile learning in a way that enables them to make considered decisions about its value in their teaching. It has been instructive over the years to reflect on how we can engage faculty in critical assessment and adoption of new technology if they perceive that it will bring them no personal benefit or that they have no time. Given that mobile technologies raise a number of problems for academics, including issues of cost, accessibility and the ability to imagine redesigning learning for mobile access, the widespread and largely enthusiastic adoption of mobile and social technologies in daily life may be more persuasive than conventional case studies which often relate to disciplines or particular contexts too far removed from an individual academic's sphere of interest. Our research with mature learners using mobile devices in their lives and learning is a useful way to demonstrate that learners are increasingly taking the lead in exploring possible applications of mobile technologies to make their studies more effective, enjoyable or convenient . This research also challenges the common preconception that mobile devices are not suitable for academic study, by providing evidence that learners can and do use their mobile phones and other portable devices to engage in academic activities such as reading journal articles. --- Proposal: Faculty as Lifelong Learners Mobile learning covers a very wide repertoire, from elaborate, technologically advanced experiments to on-the-go access, conversations and simple transactions. The entry point for faculty is likely to be at the simpler end, with convincing everyday uses proving their worth and adoption in teaching and learning then more likely to follow. Given this gradual process, the broader framework for the adoption of mobile technologies and social media should be lifelong learning, which can be defined as "The combination of processes throughout a lifetime whereby the whole person experiences social situations, the perceived content of which is then transformed and integrated into the person's biography resulting in a continually changing person" . Both the personal and social aspects of this development are well aligned with the personal and social nature of the current generation of mobile technologies. Such a changing person will need to exercise considerable selfmanagement, self-monitoring, self-awareness and meta-learning . Knowles saw adult learners as autonomous and self-directed, with an orientation to what is relevant and practical, while Kolb highlighted experience as a source of learning and development; furthermore, Lave recognized social interaction in a 'community of practice' as a critical component of situated learning. All these aspects will continue to be important in faculty development for social media, social networking and mobile learning. Faculty members ought to be able to commit to lifelong learning, remembering that "professional role model" to students is one of the main roles of the teacher, besides other roles such as planning, facilitation and assessment . A role model should know how to make best use of the powerful tools that learners carry around with them at all times, and be able to demonstrate appropriate academic uses or talk knowledgeably about effective practices enabled by those tools. Increasingly, mobile technologies are also changing how research is conducted within academic disciplines; for example, collection of new research data may be done in a participative way using the devices carried by learners in their pockets. Herrington et al. suggest that faculty who used an iPhone or iPod Touch as part of their School of Education mobile learning project should not only use the device in their teaching but also to enhance personal productivity and to research their pedagogical practice, taking advantage of the facilities to take photographs and make voice and video recordings. It has been suggested that ultimately students will be "active collaborators" in the teaching and learning process, becoming co-creators of knowledge along with other students, teachers and education leaders, engaging with project work and inquiry-based learning . The Higher Education Academy in the UK put forward the idea that universities need to improve the research-teaching nexus, and to help realize this goal, all undergraduate students should experience learning through, and about, research and inquiry. Healey & Jenkins further advocate moving more curricula in the direction of "developing students as participants in research and inquiry, so that they are producers, not just consumers of knowledge" . If it is understood that mobile devices can support academic staff in their research and in the task of inducting students into inquiry approaches to learning , these could be strong reasons for greater personal engagement with what mobile technologies have to offer. Ultimately faculty need to plan and revisit their own development in a self-directed way within a community of learning , taking into account the various aspects of their role and their own professional learning needs. A high level development plan which may assist in this process is presented in Figure 2. It reflects the assumption that faculty are engaged in teaching, research, and lifelong professional learning, and will be particularly relevant to those who are responsible for teaching delivery and curriculum design. Given earlier comments about active collaboration and the importance of strengthening the research-teaching nexus, the plan suggests that faculty development can, and perhaps should, take place in conjunction with faculty activity in developing their students. Although at first glance mobile technology does not seem to be an essential ingredient in this plan, codevelopment of faculty and students is facilitated by the use of mobile technology, which easily accommodates self-direction, cooperation, and a multi-faceted perspective on self and others. Mobile learning will continue to develop rapidly due to external influences as well as pressures and opportunities within institutions. The provision of mobile textbooks outside the sphere of influence of the academy is one such example ). Faculty will need to stay informed about these developments, which is considerably easier if they themselves are actively engaged in using mobile tools for teaching, research and learning. --- Conclusion In this paper we considered how the higher education workforce needs to adapt to the conditions created by a world which is fast becoming saturated with personal and social technologies, and is characterized by increasingly diverse student populations including those for whom social networking and the use of mobile devices is an unquestionable part of how they learn. We have considered a range of development opportunities offered in higher education and at The Open University, reflecting on how our strategy and tactics have been changing in recent years, against a landscape of change in higher education and in ways of conducting educational and professional development. Evaluation of the Mobile learning Guide showed a good level of interest in mobile learning; however academic staff were deterred by the perceived amount of time and effort they would need to invest in understanding mobile learning when it was considered peripheral to the delivery of their courses. There was some scepticism about the use of mobile technologies in delivering courses but also evidence of shifts towards more positive views when benefits became obvious. One way to enable identification of benefits is through Mobile Learning Experiences. However, to fully engage with mobile technologies, faculty need to acknowledge that they are professional role models to their students. This means adopting a lifelong learning stance and embracing the opportunity to combine research and inquiry with teaching and learning. Mobile learning is finally surfacing in higher education as a prominent technology after several years where interest was confined to researchers and relatively small numbers of innovators and early adopters. This is in line with predictions from The New Media Consortium's Horizon 2011 Report, which placed "time-to-adoption" of mobiles at one year or less. The authors of the report furthermore observe that a shift has taken place: "The 2010 Horizon Report placed mobile computing on the near term horizon, with an emphasis on the wide range of activities that are now possible using mobile devices. This year, mobiles are here because so many people use them as their first choice for accessing networked resources" . Mobile learning is no longer separate from social networking and everyday access to information and resources. For this reason, it needs to become an integral part of higher education practice.

In a time of change, higher education is in the position of having to adapt to external conditions created by widespread adoption of popular technologies such as social media, online social networking and mobile devices. Faculty members need opportunities for concrete experiences capable of generating a personal conviction that a given technology is worth using and an understanding of the contexts in which it is best applied. The paper examines approaches to educational professional development at The Open University and elsewhere, including recent initiatives related to faculty development in relation to mobile learning. It sets out what can be learnt from these experiences and proposes a plan for co-development of faculty and students in a lifelong learning perspective. Given that 'professional role model' to students is one of the main roles of the teacher, the author argues that faculty engagement should go beyond technology adoption in their teaching to adoption in research and lifelong professional learning.

Background Body weight and its perception is an important aspect of health and constitute a significant role in physical and mental well-being. The World Health Organization uses the body mass index to categorize weight status. The BMI is calculated as the weight in kilograms divided by the square of the height in meters . A BMI <18.5 is considered underweight and >25 overweight. Falling between these ranges is normal weight. Based on this definition, the WHO estimates more than one billion adults to be overweight and three hundred million of them to be obese [1].Obesity is a well-known risk factor for cardiovascular diseases [2], diabetes [3] and decreased life expectancy [4]. Much less investigated and even less discussed is being underweight. Underweight people are at risk for irregular menstruation [5], weak immunity [6] and osteoporosis [7]. Current prevalence of different body weights show varying trends in different parts of the world. The majority of these studies are from the developed world. A study of 2032 high school male and female students across the U.S., grades 9 through 12, found 1.5% of students to be underweight and 51.2% and 47.4% to be normal weight and overweight respectively [8]. Another study, focused on 360 first year female university students in South Africa found 7.2% to be underweight and 10% overweight [9]. In Pakistan, few studies are available to ascertain the prevalence of weight status. One study of 284 schoolchildren in Karachi found that 52% were underweight [10]. The results are strikingly different from the studies elsewhere although effects of age-group have to be kept in mind. In Pakistan, socio-economic level plays a major role in weight status and is a focus of the study done previously [11]. No studies of weight perception can be found despite the fact that it influences eating habits and other aspects of mental health in Pakistan [12]. Regardless of whether a person is underweight, normal or overweight, weight perception is an important determinant of nutritional habits and weight management [10]. Discrepancies between true weight and weight perception can have serious implications. Normal or underweight adolescents, who perceive themselves as overweight, are at risk for eating disorders such as anorexia nervosa [13]. Conversely, overweight adolescents perceiving otherwise are unlikely to control diet or engage in physical activity [14]. Aberrant weight perceptions can lead to risky behaviour [15] such as smoking cigarettes and skipping breakfast. Underweight women are more likely to have poorer psychological health than normal weight women. In contrast, overweight and obese women are more likely to have poor health related behaviours and lack of internal locus of control compared with normal weight women [16]. The psychosocial, psychological and behavioural implications are significant. Females are sensitive to the effects of weight perception [17] and studies have shown that they perceive weight incorrectly [18][19][20][21]. The problems with weight and weight perception are universal but greatly influenced by social norms. Current studies are heavily concentrated in the developed world. More widespread studies are needed to properly assess the importance of the patterns and perceptions of weight status. There is a lack of information from the South Asian population. Preventive strategies, dealing with the psychological risk at an individual level and body norms in media can be addressed. It is important to study health behaviour of young adults because the rapidly changing conditions in the world are bringing about changes in behaviour, and behaviour formed in the second decade of life has lasting implications for the individual in particular and the public health in general [22]. This study was done to explore the relationships between body weight perceptions, actual body mass index and weight control behaviours among the female students of Karachi, Pakistan. --- Methods --- Study population A cross sectional study was carried out from September to October 2009 on female university students in the city of Karachi, Pakistan. Eight well-recognized universities in different areas of Karachi were approached, of which four refused participation. Each of the remaining four universities was dedicated to one field of study; medicine, the arts, business and engineering. The sample, 400 female students, was equally divided between the four institutions to make it as representative of the female student population as possible. After obtaining written consent, students were requested to fill out a questionnaire and proceed to a private area to have their height and weight measured. Although we approached 100 students at each institution, the final completed questionnaires in hand were 88, 100, 96 and 99 respectively from the four institutions. The loss of questionnaires was due to various reasons including students refusing to continue mid-way, leaving the institution unannounced and misplacing questionnaires. Hence, our overall response rate was 95.8%. Students with a diagnosed eating disorder, depression, heart disease or diabetes were excluded from the analysis. We also chose to exclude questionnaires in which measurements of height and weight were not available. As a result of these criteria, 7 students were excluded due to missing height and weight measurements and 38 due to the diagnosis of the chronic conditions listed above. The final sample size included 338 female university students. --- Questionnaire The questionnaire for this study included 35 items divided into five sections. It contained questions about demographic characteristics, self-reported measurements, weight satisfaction, weight-changing practices, physical activity levels, body shape concerns and reasons for weight concern. Physical activity and body shape concern was assessed using validated tools . --- Measures --- Actual weight status Height and weight were measured after completion of the questionnaires by two separate investigators. Height was measured to the nearest 0.1 cm using a set square and standard calibrated scale against a wall. Weight was measured to the nearest 0.5 kg using a calibrated digital scale. Measurements were collected with participants in either thin socks or barefoot and with heavy clothing items removed. Body mass index was computed as weight in kilograms divided by the square of height in meters and categorized according to the World Health Organization modified Asian criterion [23]. This sets normal BMI as 18.5 to 23.0, with anything below or above this range as underweight and overweight respectively. --- Weight perception Participants were asked to describe their body weight in terms of the following responses: underweight, slightly underweight, normal, slightly overweight, and overweight. These five responses were collapsed into three; underweight, normal and overweight in the analysis. This item was used to reflect self-perception of body weight status. They were not asked about their perceived height and the ideal weight according to the height. --- Weight-changing practices Items in the questionnaire asked participants what they were trying to do about their perceived weight; lose, gain, maintain or nothing at all. The amount of weight change desired was asked. Similar items questioned weight-related practices and methods employed to modify weight. --- Body shape Female body shape is the cumulative product of a woman's skeletal structure and the quantity and distribution of muscle and fat on the body. To measure concerns with body shape, a shortened 8item version of the Body Shape Questionnaire developed by Evans et al. was used [24]. --- Physical activity The last 7 day, short form of the International Physical Activity Questionnaire was used which was developed as an instrument for cross-national monitoring of physical activity and inactivity [25]. Specific criteria were used to categorize participants into low, moderate or high physical activity levels according to IPAQ instructions. --- Ethical statement The study was granted approval by the Ethics Review Committee of the Aga Khan University, Karachi. Informed written consent was obtained through a consent form that was given to the participants along with the questionnaire. --- Statistical methods The data from the questionnaires was entered using Epi-data 3.1. Data set was exported to SPSS v.15 for complete analysis. Statistical analysis was carried out for the complete sample as well as for three different groups which were created according to measured BMI: underweight, normal and overweight. Mean values and standard deviation for all continuous variables: weight, height, BMI and BSQ score for all groups were obtained. Frequencies for each categorical variable were calculated for each group as well. To determine the differences regarding each categorical variable in each BMI group,chi sq test was done. The difference between the weight status and perceived weight was statistically significant on application of Chi-square test. --- Results The mean age of the 338 participants enrolled in the study was 20.64 ± 1.49 years . --- Actual weight status The mean weight, height and BMI of the participants were found to be 53.81 kg , 1.61 m and 20.89 respectively. Based on measured BMI; the prevalence of underweight, normal weight and overweight females was 27.2%, 51.5% and 21.3% respectively . --- Perceptions of weight status As a whole, over one third of the sample misclassified their weight status . Among females who were actually underweight , 54.3% perceived their weight status correctly and 45.7% thought they were of normal weight. No one who was underweight perceived them self as overweight. Among the normal weight , 66.7% perceived their weight status correctly, 9.8% thought they were underweight and 23.6% considered themselves overweight. Overweight female students were found to have more accurate judgment; 80.3% correctly perceived themselves overweight whereas 18.3% considered themselves normal. Only one female student thought she was underweight despite being overweight. --- Weight related perceptions and practices Underweight, normal weight and overweight students differed significantly with regard to perceptions of weight, weight goals and weight loss practices. These differences are shown in Table 3. Underweight females, being most satisfied with their weight , were mostly doing nothing about their weight . One fifth were trying to gain weight and a very small percentage was trying to lose. They also had the least negativity towards themselves about their weight . Just above half skipped breakfast but not many were actively avoiding certain foods because of their weight . Females who were at normal weight shared similar low negativity towards themselves but also lower satisfaction with weight . A quarter was still trying to lose weight. Almost half were not trying to change their weight at all which corresponds to their weight category. Very few were still trying to gain. Approximately half of the normal category were both skipping breakfast and avoiding certain foods . Overweight females, having the most accurate perception of weight, were the least satisfied with their weight although negativity was equally present and absent . Overweight females skipped breakfast the most and avoided foods the most . Just under half were trying to lose weight with 27.5% doing nothing about their weight. No overweight female was trying to gain weight. Table 4 compares the 'perceived' weight groups on the basis of weight goals. The weight goals according to perceived categories were very similar to the weight goals of the measured categories despite the fact that one third of females misperceived their weight. 5. --- Physical activity According to IPQA specific criteria majority of students, 58.28%, were classified as 'low' physical activity levels. Physical activity levels were found to be mostly low in all categories relative to BMI as well. 63.04% of underweight females reported low physical activity levels, as did 54.6% and 51.39% of normal and overweight females respectively. The highest percentage of females with high physical activity levels was observed in the overweight category. --- Discussion Our socio-demographics revealed that our study population was mostly unmarried, healthy female students. Our mean BMI of 20.89 ± 1.49 falls in line with other studies performed on similar target populations in Pakistan [26,27]. Based on this result, it can be asserted that although we had a convenience sampling, the similarity in mean BMI with other studies counters the presence of any strong bias in our results. The breakup of our sample into weight categories according to the WHO Asian criterion showed that just more than half of our sample was of normal weight with an approximately equal proportion being underweight and overweight; underweight being slightly higher. This distribution is similar to the one reported in other studies performed on university students in Pakistan [27,28] but is strikingly different to results from studies in the west. The proportion of underweight females in similar target populations from the west is much lower and varies from 3 -18% [8,9,16]. The proportion of underweight female students in our study is similar to other studies from Pakistan [27,28] but higher to other Asian countries such as India [29] and Lebanon [30], where the underweight females were found to be 12.1% and 12.4% respectively. Studies from Pakistan that comment on the underweight status of young female adults are scarce. Regarding proportions of overweight, our results fall in line with studies from other countries such as America, South Africa and Swedan [8,9,16] in which overweight ranges from approximately 10 -25%. This suggests that the difference in prevalence of overweight status from east to west is much less as compared to the difference in underweight status. In all studies, the normal weight status follows similar trends in proportion. The higher proportion of underweight status is of concern as it put females at risk of many health issues i.e. menstrual irregularitites, osteoporosis and weak immunity [5][6][7]. Previous research on weight perception has shown that female students do not have a realistic perception of their actual weight [18][19][20][21]. One third of our study population misclassified their weight which mirrors this assertion and has been shown in other studies [20]. Approximately half of the underweight females in our study perceived themselves as normal which implies that underweight students may not want to gain weight but would prefer to remain underweight. The same concept applies to the normal weight students who perceive themselves as overweight as they may attempt to unnecessarily reduce weight to meet their inaccurate normal standards [31]. The tendency of underweight females to perceive themselves as normal is frequently observed [8] but the emphasis usually shifts to normal weight females perceiving themselves as overweight. These normal weight females may undertake unnecessary weight loss which is a more apparent issue than the risks of remaining underweight. The more significant finding was the perception of normal weight by underweight females which may have its roots in a wider social and cultural acceptance of thinness. Our results show that the normal weight females had a fair level of accuracy in weight perception. We found that overweight females had the most accurate perception of weight and this has been shown to be the case in other studies too [32]. Our results indicate that the highest weight satisfaction was seen in the underweight group. This is potentially dangerous as these female students are less motivated to normalize their weight, which was seen in the high percentage of them doing nothing about their weight. Reassuringly, very few underweight females were actively trying to lose weight but on the other hand. This shows the poor weight related perceptions in the underweight group. A fairly large part of the normal and overweight groups were not satisfied with their weights which have also been reported for female students in the UK [33] and undergraduates in the US [34]. The high level of dissatisfaction among the normal group is worrisome as a quarter of them still want to lose weight. The high level of dissatisfaction and active weight loss practices among the overweight group are justified. However, it is important to emphasize realistic weight loss goals and acceptable weight loss practices. Skipping breakfast and actively avoiding foods was seen across the board with a tendency to increase with BMI. These unhealthy practices have been associated with greater levels of fatigue [35], increased weight gain [36], and irregular menstrual cycles [37]. A unique finding in our study is the assessment of weight goals in the perceived weight categories. The results are very similar to the weight goals of the measured weight categories. This indicates that although many studies report weight perception as a better indicator of weight management behaviour [8,9], it seems that this is not applicable to our population. It appears from the results that despite weight perception being inaccurate overall, the weight goals did not differ significantly between perceived and measured weight groups. Selfperception of weight did not supersede true weight in influencing weight goals. Further studies should be done to evaluate this trend and to determine the possible other factors, such as socio-cultural pressures or lack of weight-related knowledge, that may be responsible for poor weight goals. Comparing the mean BSQ score of our study with others [38] we encountered a slightly lower value, portraying the students being less concerned about their body shape overall. Correlating weight subgroups with the mean BSQ scores however, we did find an increase in mean BSQ scores from underweight to overweight students. This is consistent with other studies which show a positive association between mean BSQ scores and BMI [39]. Thus, body shape does concern female students in our population but not as much as other studies have shown. Trends in physical activity as highlighted by previous studies [38] reveal persons with normal BMI engaging in more exercise than the underweight or overweight groups. We observed a different trend, with low physical activity being the majority in all three weight groups. High levels of physical activity were reported most frequently from the overweight group, where weight dissatisfaction was high and the majority was trying to lose weight. Regardless of the physical activity levels in each subgroup, the majority of our entire sample reported "low" physical activity levels. This indicates a poor prevalence of physical activity among female university students in the city which should be a cause for concern. --- Study limitations It was a cross sectional study on female university students of Pakistan. Gaining admission to university must involve some selection for socioeconomic status , more urban upbringing, and perhaps better health. The findings of our study may not be generalized to Pakistani women of the same age. We had a convenient sampling of both institutions and students. To reduce the bias introduced, we tried to represent female university students as accurately as possible by choosing students of different disciplines and exclude students who may not be in control of the quality of their diet and exercise level . Additionally, voluntary participation in a study that involves anthropometric assessment could have caused a bias towards students who do not have weight issues. We also could not account for students who chose not to answer our additional questions or who reported their responses incorrectly. Also, the reasons for the different weight perception among the participants were not assessed. --- Conclusions Our study has shown that among female university students in Karachi, the prevalence of being underweight is comparatively high. There is a significant misperception of weight, with one third of students misclassifying themselves. Despite the misperception of weight, weight goals were not seen to be very different among measured and perceived weight groups. Health policy makers should Large scale longitudinal studies should be performed in Pakistan dealing with weight perception and specific aspects of dietary habits, body shape and physical activity. --- Competing interests The authors declare that they have no competing interests. ---

Background: Body weight and its perception play an important role in the physical and mental well-being of a person. Weight perception is found to be a better predictor of weight management behaviour as compared to actual weight. In Pakistan, studies have been done on the prevalence of weight status but weight perception is still unexplored. The study was done to examine relationships between body weight perception, actual weight status, and weight control behaviour among the female university students of Karachi. Methods: A cross sectional study was carried out during Sep-Nov 2009 on female students in four universities of Karachi, Pakistan. Our final sample size included 338 female university students. Height and weight were measured on calibrated scales. A modified BMI criterion for Asian populations was used. Results: Based on measured BMI; the prevalence of underweight, normal weight and overweight females was 27.2%, 51.5% and 21.3% respectively. As a whole, just over one third (33.73%) of the sample misclassified their weight status. Among underweight (n=92), 45.70% thought they were of normal weight. No one who was truly underweight perceived them self as overweight. Among the normal weight (n= 174), 9.8% thought they were underweight and 23.6% considered themselves overweight. Among the overweight (n=72); 18.3% considered themselves normal. Only one female student thought she was underweight despite being truly overweight. Conclusions: Our study shows that among female university students in Karachi, the prevalence of being underweight is comparatively high. There is a significant misperception of weight, with one third of students misclassifying themselves. Underweight females are likely to perceive themselves as normal and be most satisfied with their weight. Health policy makers should implement these findings in future development of health interventions and prevention of depression, social anxiety and eating disorders associated with incorrect weight perception among young females. Studies that employ a longitudinal approach are needed to validate our findings.

Bodies of Contrast in Taijiquan "Hang the flesh off the bones" is a striking mantra that Author 2 first encountered in October 2016, when he checked a potential fieldwork site for ethnographic information on the martial, meditative and healing art of Taijiquan . This began to form the basis of an interdisciplinary, social scientific and empirical, qualitative project examining how adult British students learn about their anatomy through Taijiquan and how another group learns about the anatomy of weaponry through historical European martial arts . Over the last two years, Author 2 has immersed himself in the weekly classes and social events of the two case study schools, and this particular article deals with the case of Taijiquan in an effort to uncover some of the fundamental transformative exercises used to develop the idealized body in this art. Since the official start of the project in spring 2019, the mantra of "hang the flesh off the bones" and its variants have continued to be uttered in a slow and soothing manner by the amiable and gentle instructor, David , who runs twice-weekly classes and regular workshops on Taijiquan, and related "internal" health and spiritual arts such as Neigong, in the United Kingdom. The unusual command of "hang the flesh off the bones" literally asks the student to follow "a sequence of events" by first using their intention and awareness to pull up their own skeleton from the crown point of the cranium while eventually dropping the sacrum and tailbone, and then to imagine relaxing their musculature with gravity in order to sink the mass into the ground-a key principle for success in this art, known as Song. Whereas the former action of Ting is possible via setting and maintaining correct posture, the latter, relaxed control of Song is a quality that must develop over months or even years. The utterance "hang the flesh off the bones" is part of a series of unusual commands that form part of David's inclusive yet strict pedagogy to develop the Taijiquan body-a soft, relaxed, yet alert bodymind. This bodymind is one in which the mind and body have been unified through a process of self-cultivation to develop the person in a holistic manner [1] as understood through different models of the mind-body connection, such as the energy systems seen in East Asian pedagogies [2]. This sequence of events forms the logic behind David's pedagogy involving a step-by-step process of transforming his students in a holistic and long-term manner. As Ryan notes [3], Taijiquan in Britain is commonly associated with health and wellbeing rather than martial artistry and self-defense. Within the health, fitness and wellness industries, there is an array of martial activities available for the discerning student, and "the School of Inner Arts" is one of many Western interpretations of Taijiquan as taught as a strict, systematic awareness. The School's activities differ from the more popular, simplified versions of the art developed in the 1950s for state-controlled health in the People's Republic of China , and could be regarded as a reinvention of tradition. Indeed, Bowman [4], drawing on Ryan [3] and Frank's [5] analysis, has recently reflected that Taijiquan is a quintessential example of the paradigm of a "traditional Asian martial art" that is actually a tradition of invention. One such invention is the combination of Taijiquan with other practices not normally seen elsewhere, such as meditation and specific approaches to self-cultivation. As Frank [5] has noted in his ethnographic research in China and the USA, Taijiquan is commonly connected to notions of "the little old Chinese man" and medicine, where old Asian bodies, moving slowly to heal themselves, are seen as the archetype of the martial art. This is undoubtedly the consequence of public perception of slightly built, elderly Chinese teachers depicted in Smith's [6] early text, including his master, Zheng Manqing, who developed his own version of the Yang family short form via his interpretation of the art and its "internal" principles. Conversely, yet connected to this lineage, the School of Internal Arts is led by Malcolm Reeves , a charismatic, athletic, white British man and accomplished Taijiquan practitioner in his late 30s who has studied the martial arts since early childhood. Through his travels to China and South East Asia, Malcolm became a disciple of several reputed teachers of the Yang family style, and now teaches in Portugal and Sweden, where he leads his reputed international organization while writing numerous books and translations of Chinese treatises or 'classics' such as the Daodejing. He also hosts a regular podcast and YouTube series with thousands of followers and subscribers around the world-many of them having relocated to train with him full-time. As such, Malcolm represents a new generation of Western "influencers" in Taijiquan, spirituality and wellness. In Malcolm's particular 'internal' martial arts organization concerned with a Daoist cosmology of wellness, ecology and spirituality, the ideal body is not one of overt muscular contraction and outer strength, but one of expansion and inner power in which the visible contours of the body slowly disappear . Contrasting with the Western logic of medicine and bodily training, this body is supposedly a powerful body, and through being powerful, is a healthy body. The Taijiquan body, according to Malcolm's studies and public interpretations of the Chinese medical theory of the Yijinjing , as explained on his YouTube channel, will eventually develop a tendon-like quality in which the practitioner develops strength, mobility and explosiveness alongside many mental qualities of a relaxed alertness. As an animal lover, Malcolm's senior student and representative, David, likens this mind-body quality to a cat waiting to spring on a mouse: it is relaxed and completely focused on its task, never distracted and ready to pounce when necessary. It is important to note that the art now known as Taijiquan has developed since the 17th century in China under various names and formats. The slow, supple movement of modern Taijiquan is deeply rooted in traditional Chinese cultural thought, philosophy, medicine and martial arts [7]. The form of Taijiquan practiced today may be understood as traditional Chinese martial arts-based calisthenics, supplemented with a range of related exercises and physical practices , which can be regarded as a constitution and integration of traditional Chinese philosophy and health principles through breathing techniques and martial arts [8]. Within China and across the Chinese diaspora, Taijiquan has long been regarded as a Chinese "cultural treasure", and this adds to a growing global interest in the martial arts as a form of living cultural heritage now recognized by UNESCO [9]. The Chinese philosophy drawn on in Taijiquan is mainly based on Confucianism, Daoism and Zhouyi, which takes the Taiji and Yin-Yang dialectical concepts in Daoist philosophy as the core ideas. The central doctrine of Daoism is focused on mental tranquility, and its goal is to achieve longevity by meditation and lifestyle modification [10] . With its competing histories, modalities and philosophies, Taijiquan includes different family styles and combinations and deviations from these. Taijiquan is currently thought to have developed from a military training exercise into a Daoist-informed art for a multitude of purposes, such as the training of actors [11]. As one of G's former informants in another influential organization [12] once put it, Taijiquan "is a broad church" [13]: from the practical approach focusing on self-defense applications to the more accessible health-oriented art. The School of Internal Arts sits somewhere along the middle of this spectrum; it follows the Yang family tradition of Yang Chengfu for the 37-posture short form and the lesser known Yang Shaohuo for the grueling and more martial long form. Our analysis of pedagogy and practice in this article focuses on the former, more accessible training in public classes, as David does not have permission from his teacher to openly teach the long form. The ideal Taijiquan body permits great variety in terms of size, shape and outer appearance, as it is chiefly concerned with internal feel and function of movement. The eventually rotund body of the mature Yang Chengfu led him to develop a "large frame" for these techniques, but his physique would be regarded as morbidly obese in today's society. Other late masters, such as the slightly-built Zheng Manqing , conformed to the stereotype of what Adam Frank [5] explored in terms of age and ethnicity: the seemingly frail, little, old Chinese man who actually has a powerful body. It is important to note, however, that each martial art has its own idealized body. The physique of mixed martial arts fighters is typically toned and callused-capable of giving and receiving pain [14]. The Aikido body, in contrast, is one that is ideally bottom-heavy and dense, making it difficult for the practitioner to be thrown due to a low center of gravity [15]. These ideal bodies are informed by specific philosophies of the body, health and life in general. In the next section, we examine one key text on bodily transformation, the Yijinjing, that has been reinterpreted by Malcom Reeves in order to guide all the training undertaken in the School. This article draws on ongoing ethnographic fieldwork on the School of Internal Arts to highlight several key exercises used to develop specific elements of the idealized Taijiquan body. These help address our leading question: how, as adults, are Westerners learning to re-educate their varied, individual bodies through prolonged and intense Taijiquan and Neigong training? As a collaboration between a Chinese and British martial arts researcher, the paper first outlines the research on Yijinjing and Taijiquan in China before moving to account for the ethnographic methods and our cross-cultural, multilingual analysis. We then offer a detailed description and illustration of exercises for the spine, scapula, Kua and feet which form the logical basis of particular body conditioning in the art of Taijiquan and the School of Internal Arts' corresponding approach to Neigong: what we call the Taijiquan-Neigong body. We then offer some conclusions and future directions for research on the re-education of the body through practices and pedagogies informed by Eastern philosophy. --- Taijiquan-Neigong Pedagogy and the Yijinjing As with Taijiquan, there are different opinions on the origin of the Yijinjing. From the current Chinese-language literature, most scholars believe it was created by the mystical Indian monk, Bodhidharma. According to legend, Bodhidharma came to China in 526 AD and eventually arrived at the Songshan Shaolin Temple. In order to alleviate the stasis of energy and blood caused by Zen sitting meditation practice, he supposedly practiced martial arts and Dao Yin techniques to move the muscles and bones, and modified and improved them, forming a fitness method named "Yijinjing". Secretly spread among the Shaolin monks [10], the purported original purpose of Yijinjing was, thus, to reduce the fatigue and sleepiness caused by Zen practice to a certain extent, so the created movements are mainly joint extension exercises such as stretching and kicking. "Yi" means change, "Jin" refers to meridians and muscles and bones and "Jing" means ways and methods. In terms of its etymology, Yijinjing is thus a method to change the muscles and bones . In the process of the spread of the traditional Yijinjing, it has been studied from different perspectives such as religion, Yin-Yang and the five elements, and different schools have been created [16]. In the 1980s, "Qigong fever" emerged in China, and Qigong exercises were unprecedentedly popular, involving all parts of the country. In order to ensure the healthy and orderly development of Qigong fitness activities, and to make them scientific, standardized and legal, in 1996, the National Sports Committee of China first proposed the concepts of "social qigong", "health qigong", and "qigong medical treatment". In 2000, the State Sports General Administration again coined the term "Health Qigong", a traditionalist national body culture that combines physical activity, breathing and psychological adjustment as the main forms of exercise. This is a component of the long-standing Chinese culture. In June 2001, the Health Qigong Management Center of the State General Administration of Sports was established, and the Yijinjing was adapted into the new exercise method "Health Qigong-Yijinjing". This is one of the first four sets of Health Qigong exercises promoted by the Chinese national government [17]. Nevertheless, Chinese scholars rarely conduct research on Yijinjing and Taijiquan outside China [18,19], such as on the spread and development of these practices and the meanings around the fitness effect of Yijinjing and Taijiquan on foreigners. This is accompanied by a lack of research into the local integration and development of Yijinjing and Taijiquan. Chinese scholars generally use the literature methods and experimental methods to study Yijinjing and Taijiquan [20][21][22][23][24][25][26], but eschew, for example, the type of ethnographic research used in our article. Taijiquan has started to be used in Western countries such as Britain as an adapted exercise in prisons [27] or as a morning routine in primary schools [28]. This is a relatively new and non-standardized phenomenon, and it is not something that the cohort of mainly white British students in the School of Internal Arts learned as children in their formal physical education lessons as part of the UK National Curriculum [29]. Instead, their education in Taijiquan began as mature adults, aged from their early thirties to mid-sixties, after earlier exposure to Qigong and martial arts such as Karate or Aikido. Their bodies, minds and selves are molded into the School's specific ideal based on the eclectic approach to Yang family Taijiquan and Neigong-the dispositions expected of the institutional martial habitus that adds to each person's biographies [30]. Malcolm is now turning his attention to digital broadcasts explaining what he regards as the true interpretation of the more medical text on transformation, the Yijinjing. For Malcolm and his followers, the modern understanding of the Yijinjing is incorrect, as for him, the original text does not prescribe a set of exercises, but is instead an introduction to a distinct set of principles. Following this logic, by adhering to the principles of the Yijinjing, a Taijiquan practitioner is seen to be practicing in the correct, internal manner. According to this interpretation of his own beloved mantra, "skeleton up, flesh down", the body's tissues will lengthen, and become more elastic and stronger through the hanging of the flesh over the bones. Following this logic, the physique of the practitioner will eventually possess "a tendon-like quality" that is powerful and explosive: like David's analogy of the cat waiting for a mouse. This article works from the premise that physical education does not stop upon the last day of school, as it can be argued to be a lifelong pursuit, like education in general. Moreover, just as there can be physical education, we see the potential for physical reeducation of the human being in later, alternative forms of pedagogy such as Taijiquan. As such, as part of a special international, interdisciplinary and intercultural issue of the International Journal of Environmental Research and Public Health on physical education, this article explores a form of re-education about the body, health and movement in the martial and meditative art of Taijiquan. It specifically focuses on David's evening classes and online recorded classes during the lockdown and local COVID-19 restrictions in the UK. Through thematic analysis, we argue that a particular approach to Taijiquan as an experiential and folkloric body culture [31] shapes new understandings of seemingly rudimentary activities such as standing still, walking and moving with poise and control. Taking an eclectic theoretical approach from an interdisciplinary lens, we draw on two years of ethnographic field notes as well as interviews with David and video analysis from Malcolm's podcasts in order to examine his alternative pedagogy, philosophy and the phrases that unite the Daoist worldview with the stillness and movement in this martial art. In the next section, we outline the research project and how the linguistic pedagogy was studied. We then turn to the analysis of the phrases linked to specific practices and techniques of the body, designed to develop particular aspects of the Taijiquan-Neigong body. This leads to a discussion, not just of what a body can become through the use of such concepts as linguistic bodies [32], but, as Spatz [33] questions, what a body can do. In this case, with a soft, relaxed, alert and powerful body, an exponent can move in an explosive fashion for self-defense. --- The Cross-Cultural, Collaborative Study As well as being an extension of Author 2 's dual ethnographic study of HEMA and Taijiquan, this project is part of a wider collaboration between Chinese and British martial arts scholars seeking to uncover the ways in which Chinese Taijiquan culture is being transmitted in the British context. More specifically, this article follows the principles of traditional ethnography, which is, quite literally, the in-depth study and written representation of a group of people with a common culture. As set out in Hammersely and Atkinson, ethnographic fieldwork involves immersing oneself into the social life of a group of people to study their interactions, organization and practices via a combination of participation, observation, interviews and other qualitative data collection techniques [34]. This rich qualitative data is analysed on a regular basis in order to determine themes for further observations and note taking in the fieldwork site. The majority of the rich, descriptive data comes from field notes written during and directly after the social and embodied interactions with the research participants-all of which is intended to make the strange familiar and the familiar strange [35], as we will explain. Ethnography is a key research strategy in the expanding field of martial arts studies, and has taken a keen interest in the body and embodiment for many decades [36]. As a linguistic ethnography, its emerging research question is around the theme of languagenamely, how Chinese linguistic terms and concepts are embodied and lived by Western practitioners . As such, it explores ideas around human beings as linguistic bodies [35] that draw on concepts from different languages and embody these in their practice. Due to the gradual development of the bodymind in Taijiquan through its slow, systematic pedagogy, this project was planned for five years according to clear yet overlapping stages of: fieldwork; personal autophenomenographic reflections; one-on-one interviews; focus groups, and online media analysis and documentary analysis. Because of the emergent nature of ethnography as an immersive and seemingly "messy" tradition [37], these stages have been altered to blend online and offline ethnography as seen in this article [38]. This follows continued immersion in a culture and intersubjective interactions in the social world online, which is now known as netnography [39]. The setting of the School of Internal Arts was selected after George settled into a new city, and where the institutions was recommended as a place where Taijiquan was taken very seriously in a traditionalist fashion. It was a convenience sample by chance, as G could walk to the classes and stay after the training sessions for friendly discussions with his fellow students. This coincided with his simultaneous ethnographic study of historical European martial arts , which enabled a comparison of two very different kinds of martial arts, institutions, teachers and students-a blend of the relatively familiar and the strange for George, who is an experienced martial artist with a background in the Asian styles such as Wing Chun, several styles of Taijiquan, Taekwondo, Kendo and Mexican Xilam. However, the approach taken to Taijiquan in David's class was unfamiliar to George, who was not accustomed to the focus on the scapula and the Kua . After several months of initial learning in the School, the ethnography officially began in March 2019 through the direct participant observation of George, a white able-bodied British man in his mid-thirties who joined David's popular class as a beginner in this particular form of Taijiquan and a complete newcomer to the concept of Neigong. Taking the position of an apprentice, like many other ethnographers of mind-body practices [40], George gained the trust of the group and built rapport with David as the main gatekeeper of this branch of the international network. In addition to the twice-weekly evening classes held in a primary school and refugee support center, George engaged in regular meetings with his teacher, and is now undertaking one-on-one interviews with the core members of the school. From March 2020, with the advent of the COVID-19 pandemic and lockdowns in the UK, George's fieldwork turned online by adopting a netnographic strategy of taking part in the online classes and analyzing segments of the class deliberately recorded and shared with the students. George has undertaken regular thematic analysis of the field notes be re-familiarizing himself with the material and finding overlapping and recurring themes, such as embodied learning, transformation/change, Daoist cosmology and the role of humor in the pedagogy. This led him to work with Author 1 , a Chinese martial arts researcher and native Chinese speaker. During his research visit to Britain, Xiujie joined one of the classes as an observer and participant, which enabled us to discuss the content and delivery of the Taijiquan and Neigong classes. He is a Chinese man in his mid-thirties who has practiced various forms of Chinese martial arts for more than 20 years. Xiujie also participated in local Taijiquan classes in the UK, which provided some data support for the ethnographic research and comparative thematic and linguistic analysis. Later, in order to make the research progress smoothly, George and Xiujie regularly communicated and negotiated the research process through online discussions over Skype, which facilitated the discussion of embodied technique and embodied knowledge [41]. This was helpful for George's ethnographic analysis, as he was becoming very familiar with the approach taken by David; meanwhile, for Xiujie, the perspective taken on Taijiquan and the Yijinjing was radically different and strange, despite him being a native Chinese speaker. These online, cross-continental interactions enabled a cross-cultural dialogue on the different ideas around the Taijiquan and Neigong body, including Chinese/Daoist anatomy, the energetic or subtle body and the role of related practices surrounding Taijiquan. Such terms are nearly impossible to express purely in words, which is one limitation of the present form of representation as a modified realist tale [42] showing our analysis and involvement in the research process. This can be seen by our reflexive journal extract below, which illustrates the range of analogies that David employs to convey complex ideas, which in turn are expressed in a physical fashion: Using David's analogy verbalized in class, George took out a wine glass and poured water into it. He said that David believed that if the wine glass is the external form of Taiji, then water is the inner essence of Taiji. Water can be poured into wine glasses, teacups, kettles, or bowls. But the inner essence of water has not changed, and only the outer manifestation of the load has changed. In other words, no matter the external appearance of the Chen family, Yang family, Wu style, Wu family and Sun family and their differences, the inner essence of Taijiquan is the same. Therefore, David believes that the focus of attention should be how to teach the true inner essence of Taijiquan to students, rather than excessive pursuit of external forms of expression. The visual aid of the analogy in action helps the reader understand the idea that external forms are vehicles for the development of Taijiquan. In the following discussion, we turn to the interconnected teachings of Malcolm and his older apprentice David in order to examine: the theory behind the School's pedagogical practices and how specific body parts are re-developed and reconceptualized through Chinese-language concepts as part of the process of re-education. In the second section, as with the analogy above, we have used visual aids through several photographs depicting key snapshots of several of the fundamental exercises described in each subsection. "Taijiquan or Tai Chi is primarily known for its slow graceful movements and relaxing health benefits. However, Taijiquan is much more than this and works on a number of levels. It is a martial art that uses relaxed power to overcome a greater force and also a path in which to develop our consciousness. When we study Taijiquan along the classical Daoist threefold path, we bring together health, martial and consciousness practices to attain deep and meaningful change in our lives. Nei Gong, which translates as 'internal development' in Chinese, is a process of change that works with the physical, energetic and consciousness bodies, to balance our nature and give us good health. A number of moving and static exercises are used in the process to clear and awaken the energy system; these include, Qi Gong, Dao Yins and breathing exercises. We aim to awaken our energy system via the lower Dan Tien, which sits below the navel." This quotation comes from an official flyer promoting the School of Internal Arts' two main activities: Taijiquan and Neigong. David handed the flyer to George when they met for one of their breakfast discussions on the meanings behind the two arts. The form of traditionalist or "authentic" Yang Taijiquan that is proudly promoted by the institution does not focus on the overtly martial version of the system, not does it provide a very accessible, easy version of movement for beginners. Instead, the instructors teach the art in what they see as the middle of the spectrum of the aforementioned broad church: in a disciplined manner that builds on basic movement exercises designed to prepare the body and mind for Taijiquan as understood through Malcolm's translations of key Chinese principles such as Song and Ting . As Bowman [4] has noted, many Asian-language terms for techniques and concepts are not readily translated across countries. He offers the example of a Polish Judoka who felt uncomfortable with the English approach to pronouncing Japanese techniques. In Chinese martial arts, "Ting" is well known in Cantonese arts such as Wing Chun as a form of "listening energy". Accompanying the principle of Ting is its lesser-known concept of "Song" which is used in order to systematically relax and lower the body's center of gravity. The muscles, meridians and bones of the whole body are thereby stretched and lengthened. The various parts of the body are held in the best structure and are relatively long and relatively stable. By stretching and releasing, flexible elasticity is obtained. "Song" is not a state of laziness and laxity, nor a state of softness. Real relaxation means that the mind , sense and strength sink into the soles of the feet, and when they go deep into the ground the practitioner should feel that something rises from the soles of the feet, gradually filling the whole body, and pulling them up. Only with the feeling of leading upwards will the experience of sinking the whole body downwards be deepened. Only then can practitioners truly understand the essentials of Taijiquan, which is "rooted in the feet, sent through the legs, dominated at the waist, and shaped in the fingers" [43] . Taijiquan's Kung Fu or "the marriage to the pursuit of skill" in Malcolm's terms can also be said to be "Song" Kung Fu. Indeed, David often compares to Taijiquan to boxing: "A boxer's basic skill is the punch. They learn to punch all day, whereas in Taijiquan, we learn to sink the mass". In other words, a Western boxer's Kung Fu lies in their ability to punch instinctively while the Taijiquan practitioner is concerned with sinking their mass so as to be hard to move in combat. According to modern and popular conceptions, "Chinese boxing" or Chinese martial arts are generally divided into two rather divisive categories: "Internal Boxing" and "External Boxing" [44] . The history and politics behind this division has been debated [45], but these ideas remain in contemporary Chinese martial arts circles, with practitioners often referring to their previous "external martial arts" training. Taijiquan is based on the theory of Taiji, while Baguazhang is based on the theory of Eight Diagrams, and Xingyiquan is based on the theory of Five Elements, which means that they all belong to the social category of "Inner Boxing" [46]. Therefore, it can be said that Neigong is the main training content of internal boxing, while Taijiquan is a type of internal boxing that expresses a distinct, idealized Taijiquan-Neigong body. Bound by the principles of Song and Ting, the School of Internal Arts syllabus is vast, and can take over a decade or more to complete, yet alone master. From two years' fieldwork to date, George has undergone a great variety of exercises connecting to Taijiquan and other arts such as Baguazhang-some of which appear for a matter of weeks, only to reappear a year later. However, the most commonly honed body parts and exercises are: the spinal column via the spinal wave exercise; the scapula and palms through the palm push and polishing glass exercises; the Kua via Kua work and weight transfer/the eight gates, and the feet via standing postures. We explain and discuss each of these essential foundational exercises in turn by focusing on parts of the body as in Bates' [47] study of people living with, moving with and managing chronic illness. This linguistic body, as expressed by an emphasis on the spoken word, is explained in terms of the linguistic and philosophical principles inspired by the Yijinjing. We begin with the spinal wave, a non-martial preparatory exercise that can be practiced alone, at any time and place, like many other elements of this body pedagogy. These are described in detail, following the ethnographic tradition, while utilizing some images of George in action for illustrative purposes. --- Opening the Vertebrae: The Spinal Wave Contemporary Britain is a very sedentary society in which sitting constitutes a large part of most people's day, and "bad backs" or lower back pain are the cause of a significant period of time off work. Even the National Health Service have called for a reduction in the time spent sitting in order to reduce the high risk of serious illness [48]. This sedentary lifestyle and also over-specialization in movement leads to compressed vertebra-something that David seeks to remedy in his classes. Committed students come from different martial arts backgrounds, such as Wing Chun, Aikido and lesser-known styles such as Chen Hsin-all of which have shaped the body in some way. For George, the rapid, forward movements of Wing Chun coupled with weight training in his adolescence had led his body to be quite toned yet slightly hunched, thereby limiting his mobility. Seen through a Daoist lens, the Taijiquan body is seen from inside, focusing on the links between organs and wellbeing, and this begins with work on the spinal column in order to develop good posture and elasticity around the body, which later enables something understood as "inner power". Figure 1 depicts the "spinal wave", which is a gentle, rhythmic movement that initiates in the coccyx and moves up the sacrum, lumbar and other regions of the spine until it reaches the occipital bone at the base of the skull. Some students might also envisage being raised at the crown point at the top of the skull "by a golden thread", or being pulled up by a hook on the occipital bone at the back of the skull. In a typical evening class, David works in front of his 12-15 Taijiquan students lined up in two rows who are working in unison from a seemingly hunched, lifeless position, as in a puppet without a puppeteer pulling on the strings. Once their body is fully erect by stretching their spine upwards from the coccyx to the skull, they slump back down by folding the head forwards and sinking the tailbone down to bend the knees slightly. This initiates the process once again. Students then repeat the action dozens of times, while David adds variety by asking them to raise their hands above their heads while completing the motion. In Figure 1, George has deliberately selected this version of the exercise to emphasize the elongation of the spine from the profile position in three snapshots. On some occasions, student perform the exercise at a 45-degree angle. One might hear clicks in between the vertebra as they start to open. Indeed, David often shares a sense of wonder about this process, with comments such as: "Open up the space between the vertebrae", reiterating the fact that "it's so important to create space between the vertebrae". Indeed, in one online class, David stressed that "there's no reason for you to shrink as you get older", as this can be prevented by softening the bunched up areas of the spinal column through these exercises. Hence Taijiquan exercises, such as those seen in this discussion, are designed to create more space within the inner body. column in order to develop good posture and elasticity around the body, which later enables something understood as "inner power". Figure 1 depicts the "spinal wave", which is a gentle, rhythmic movement that initiates in the coccyx and moves up the sacrum, lumbar and other regions of the spine until it reaches the occipital bone at the base of the skull. Some students might also envisage being raised at the crown point at the top of the skull "by a golden thread", or being pulled up by a hook on the occipital bone at the back of the skull. In a typical evening class, David works in front of his 12-15 Taijiquan students lined up in two rows who are working in unison from a seemingly hunched, lifeless position, as in a puppet without a puppeteer pulling on the strings. Once their body is fully erect by stretching their spine upwards from the coccyx to the skull, they slump back down by folding the head forwards and sinking the tailbone down to bend the knees slightly. This initiates the process once again. Students then repeat the action dozens of times, while David adds variety by asking them to raise their hands above their heads while completing the motion. In Figure 1, George has deliberately selected this version of the exercise to emphasize the elongation of the spine from the profile position in three snapshots. On some occasions, student perform the exercise at a 45-degree angle. One might hear clicks in between the vertebra as they start to open. Indeed, David often shares a sense of wonder about this process, with comments such as: "Open up the space between the vertebrae", reiterating the fact that "it's so important to create space between the vertebrae". Indeed, in one online class, David stressed that "there's no reason for you to shrink as you get older", as this can be prevented by softening the bunched up areas of the spinal column through these exercises. Hence Taijiquan exercises, such as those seen in this discussion, are designed to create more space within the inner body. Unlike many postures in the syllabus , this spinal wave is not given a Chinese term, but is nonetheless a cornerstone exercise for the class. It is normally used as part of the warmup after the basic limbering exercises, but it is also used to ease the body after prolonged periods of standing and form sequences. George has used this exercise not only in class but in between bouts of writing and marking, as an academic who uses his laptop for extensive periods of time while seated. He has heard clicks in different places across the spinal column , which have moved location throughout his two years as a student of David. Indeed, George deliberately worked on the exercise in between Unlike many postures in the syllabus , this spinal wave is not given a Chinese term, but is nonetheless a cornerstone exercise for the class. It is normally used as part of the warmup after the basic limbering exercises, but it is also used to ease the body after prolonged periods of standing and form sequences. George has used this exercise not only in class but in between bouts of writing and marking, as an academic who uses his laptop for extensive periods of time while seated. He has heard clicks in different places across the spinal column , which have moved location throughout his two years as a student of David. Indeed, George deliberately worked on the exercise in between writing extracts of this discussion after analyzing his field notes on how David explained the importance of the movement in his usual soothing tone. George has also started the spinal wave before the beginning of a class , as students typically arrive early to ready their bodies for the intense training. "Spinal wave . . . let's do the spinal wave, George!" said Rich, an excitable, confident, intermediate student in his fifties who moved to stand by George's right side one evening, emulating the movement with a beaming smile. Rich made the exercise a shared one, as in the regular class, rather than George's solo routine of warming up. --- Mobilising the Scapula: The Palm Stretch and Polishing Glass From the spine comes another vital element of the Taijiquan-Neigong body: the scapula or "the true shoulder" as David calls it. David spends considerable time in class working on spreading and dropping the scapula in order for his students to become more mobile. Indeed, one of David's students once joked to him: "Scapula and Kua, scapula and Kua, those are your two favorite words. You mention them all the time!" As they learn new postures, students are therefore encouraged to focus their attention on the spine and then the scapula before the elbow and then the hands. In this subsection, we explore the palm stretch and polishing glass actions as a way to open up the scapula for looser and more economical movement before moving onto the Kua. In Taijiquan and Chinese medical terminology, the center of the palm is known as the Lao Gong, which is believed to be a vital energy point [49]. The palm stretch develops a connection to the Lao Gong, but this is first performed by stretching the fingers of both hands in a lateral fashion as in a crucifix. The shoulders and elbows are then relaxed by the mind until they slowly drop, which enables the palms to rise up, with the fingers facing the ceiling. The practitioner then presses the palms out to an imaginary wall by pushing from the scapula. David stresses the importance of relaxing the upper or outer parts of the arm and shoulders, and moving from the important armpit region . George shows the start and finish points of this exercise in the lower row of images in Figure 2 Very often in class, the palm stretch is followed by the polishing glass exercise. Here, students hold out their arms in front of their bodies and draw them back several inches by pulling back the scapula and then opening them out, only to push them forwards again. "Like you're polishing glass", David reminds us regarding this motion, which stays at the same height all the way through the cycle. He regularly explains the importance of scapula mobility in Taijiquan, and this is exemplified in repeated motions in the short form. When practicing Taijiquan, the body is required to relax from head to toe and from the inside to the outside. No part of the practitioner's body should be stiff. In this way, the practitioner can concentrate her/his thoughts, breathe peacefully, and move continuously. Loosening exercises as seen in the top row of images in Figure 2 are therefore used in David's class to sink the scapula and release tension from the body through the articulations of the shoulder joint, the elbow joint and the wrist joint. During Taijiquan training, shoulder joint relaxation is the most important factor. Only when the scapula of the practitioner relaxes, can the person's arms become soft and flexible. It is difficult for beginners who practice Taijiquan to loosen the scapula from the outset; only under the guidance of mind and after long-term exercise, can the shoulder joints slowly reach a relaxed state. Generally speaking, to relax the shoulder joint is to make the scapula sink. The shoulder joints of the practitioner must be level with both shoulders to relax and sink, not one high and one low, so that the elbow joint can relax and hang down. To relax the shoulder joint of the practitioner, the elbow joint must not be close to the ribs. Under the premise that the practitioner's shoulder joints are relaxed, then the entire arm can be relaxed. Therefore, in the process of practicing Taijiquan, the first thing to do is to relax and sink the shoulder joints. Only in this way can we meet the Taijiquan practice requirements of "sinking shoulders, falling elbows and sitting wrists" [43] . --- Opening the Kua through Kua Work As the reader can see, there are many complex concepts for the student and teacher of Taijiquan to remember during class and home training. The aforementioned Kua is the turning point of the waist and legs. If the Kua is not loosened, the waist and legs cannot be flexibly coordinated. Of all the joint "Song" exercises, the Kua is the most difficult, as David notes from his numerous years of trying to loosen the waist and hips after a long period in Shotokan Karate in which he, like all his students, had "hardwired tension". There are five main types of Kua loosening exercises in the School of Internal Arts. Regardless of the method, one must pay attention to the loosened waist and sinking of the Kua during each transition between techniques. Only in this way can the Kua loosen as the training time increases and the training experience deepens. David explained in one class: --- Opening the Kua through Kua Work As the reader can see, there are many complex concepts for the student and teacher of Taijiquan to remember during class and home training. The aforementioned Kua is the turning point of the waist and legs. If the Kua is not loosened, the waist and legs cannot be flexibly coordinated. Of all the joint "Song" exercises, the Kua is the most difficult, as David notes from his numerous years of trying to loosen the waist and hips after a long period in Shotokan Karate in which he, like all his students, had "hardwired tension". There are five main types of Kua loosening exercises in the School of Internal Arts. Regardless of the method, one must pay attention to the loosened waist and sinking of the The mention of the Kua as part of a rich theory on the subtle/energy body is another unusual aspect of the School of Internal Arts, although David recently reflected: "Ten years ago, no one was talking about the Kua, but if you go on YouTube now, plenty of people are mentioning the Kua". This reflects a growing interest in the internal principles of Chinese martial arts, as in re-evaluations of popular "external" systems such as Wing Chun, which is now regarded as an internal system. Social media is playing a role in this revalidation and renaissance of styles, as seen in The Martial Man's investigative videos shared by Andy, one of George's classmates, who moved all the way from South Africa to train with the School of Internal Arts in the UK and Portugal . Andy devotes his life to self-cultivation and the development of the Taijquan-Neigong body through regular classes and theoretical study of the training principles through podcasts and books by the Academy and its esteemed peers. Recently, in his own online class, David has been fond of a new phrase: "Principles, principles, principles-it's all about the principles", often adding utterances based on this need for bodily repetition, such as: "You can never do enough Kua work" in his calming tone, as students move through hundreds of repetitions of slight turns in their torsos. In fact, after two years in his class, George has gone through what must be thousands of repetitions of specific Kua movements. In one of the most common routines, students "pin the knees" as their teacher instructs them, and try to isolate the slight 30-degree angle from the invisible point of the Kua. With the command "place your fingers against the Kua", they are sometimes asked to gently press their fingertips against the superficial area on the outer body, which equates to the pubic triangle in between the hips. Students like George slowly feel their fingers pressing into the soft tissue and glands as the Kua drives the movement, which might take several seconds to move to the left, back to the center and then to the right. Due to the intimate nature of this region, David never touches students there, although he might ask their consent to adjust other aspects of the posture from the upper torso, such as when they are leaning backwards or too far forwards. George has demonstrated this personal touch on one's own Kua region in Figure 3, which demonstrates moving to the left and the right as well as sitting deep into the Kua in a Ma Bo stance. Sometimes in class, students do perform contemporary fitness exercises such as crunches, the plank and brief press-ups for general fitness and to get into "the zone" for training. However, in the main part of the sessions, these seemingly Western exercises are absent, as the tuition focuses on generic Daoist physical cultural and medicinal concepts. "Kua squats" turns the familiar "Western" exercise of squats into a more Chinese Daoist form of movement. As with some of the shoulder loosening exercises described above , we move up and down according to three different heights-transitioning from a lower extremity to a middle point and then an upper position. This continues with the trend of pulling up the head from the occipital bone and lowering the tailbone with one's intent . So, when one moves down from the Kua , the head is still pulled up in order to continue with an erect spinal column. Sometimes in class, students do perform contemporary fitness exercises such as crunches, the plank and brief press-ups for general fitness and to get into "the zone" for training. However, in the main part of the sessions, these seemingly Western exercises are absent, as the tuition focuses on generic Daoist physical cultural and medicinal concepts. "Kua squats" turns the familiar "Western" exercise of squats into a more Chinese Daoist form of movement. As with some of the shoulder loosening exercises described above , we move up and down according to three different heights-transitioning from a lower extremity to a middle point and then an upper position. This continues with the trend of pulling up the head from the occipital bone and lowering the tailbone with one's intent . So, when one moves down from the Kua , the head is still pulled up in order to continue with an erect spinal column. This Kua is likened to a gate that needs to be constantly opened and closed during practice. This is especially evident when running through the form sequence, when David calls us to "close the right Kua" or "close the left Kua". The main action is therefore the closing, while the opening is a more responsive, passive movement. The Kua is also understood as a seat for standing and bearing one's weight during the form sequence. "Sit into the Kua" is another common instruction as students shift the weight and try to sustain it, though not in our knees , but within the Kua. David likens this to "sitting on a bar stool", wherein the leg muscles do not tense, as the body is supported by the stool. This concept is taken into the fundamental exercise of standing examined next, which takes the sinking of the mass into the feet and ground. --- Compressing the Feet: Ba Men and Standing Standing in specific postures is the staple exercise of many Chinese "internal" martial arts as practiced according to the Yijinjing principles and theory. In David's class, students often hold specific stances for minutes, and this is especially the case for the opening stance seen at the top left side of Figure 4 , which is regarded as a rare yet fundamental position in the School's particular lineage, which has a South East Asian influence. As with all the other exercises explained in the previous subsections, the head is held upright from the occipital bone and crown point, the chin is tucked in, the chest is soft and relaxed, the back straightened, and the sacrum expanded with space around the armpits. George has spent extensive periods of home training, holding this and other positions during his free evenings while listening to instrumental music. He often mixes the opening stance with the neutral stance , which involves standing around in a shoulder-width position, toes slightly turned inwards so that the second toe is central, sitting into the Kua with the arms by the side. Through one's intent, students can start to turn their hands so that their palms face behind them. After an extensive period-perhaps 20 or 30 min-the feet will begin to feel an immense amount of pressure. Within class training, George has joined his fellow students in slowly limping across to get a sip of water during a brief break between exercises. The agonizing training is particularly painful in the lower legs and soles of the feet, and this is particularly the case for the Wuji stance in the Neigong part of the 2.5 h class. This stance enables the students to close their eyes for Neigong, whereas in Taijiquan the eyes should always be kept open and alert. "If your calves are hurting, that's a good sign". These "achy calves" in training might be later accompanied by an "achy Kua" feeling after a hard evening's training. One exercise that can be draining yet richly awarding at the same time is the Ba Men exercise. Although there are eight complex movements with the whole body, we normally run through the first four before moving onto the intricate techniques such as the elbow and shoulder bump exercise, which has more obvious martial connotations. All movements are driven by the closing of one Kua and the sinking of the mass onto one foot, followed by the release of mass from that foot and the closing the opposite Kua. David sometimes works on this sequence at home for up to an hour on each side, although he advocated following one of his senior students Sean's approach of drilling the basic footwork movements for ten minutes at a time on each side. "He's found his root now; you can't take that away from him!" marveled David, proud of his student's accomplishments. To emphasize the Kua and lower limb movements, George demonstrates the footwork movements for Ba Men without the accompanying hand motions in the lower part of Figure 4. Zhan Zhuang, seen at the upper right part of Figure 4, is a basic yet demanding exercise of Taijiquan, including "Song Gong" and "Zhuang Gong". "Song Gong" aims to relax the whole body through the muscles, tendons and joints of the whole body. The main thing is to loosen the shoulders and elbows, loosen the waist, and then relax the whole body. Yang Chengfu also said, "Footwork should be divided into virtual and solid; ups and downs are like cat steps, if the weight is moved to the left of the body, the left is solid, and the right foot is virtual; when it is moved to the right of the body, the right is solid, while the left is empty" [43] . toes slightly turned inwards so that the second toe is central, sitting into the Kua with the arms by the side. Through one's intent, students can start to turn their hands so that their palms face behind them. After an extensive period-perhaps 20 or 30 min-the feet will begin to feel an immense amount of pressure. Within class training, George has joined his fellow students in slowly limping across to get a sip of water during a brief break between exercises. The agonizing training is particularly painful in the lower legs and soles of the feet, and this is particularly the case for the Wuji stance in the Neigong part of the 2.5 h class. This stance enables the students to close their eyes for Neigong, whereas in Taijiquan the eyes should always be kept open and alert. "If your calves are hurting, that's a good sign". These "achy calves" in training might be later accompanied by an "achy Kua" feeling after a hard evening's training. One exercise that can be draining yet richly awarding at the same time is the Ba Men exercise. Although there are eight complex movements with the whole body, we normally run through the first four before moving onto the intricate techniques such as the elbow and shoulder bump exercise, which has more obvious martial connotations. All movements are driven by the closing of one Kua and the sinking of the mass onto one foot, followed by the release of mass from that foot and the closing the opposite Kua. David sometimes works on this sequence at home for up to an hour on each side, although he advocated following one of his senior students Sean's approach of drilling the basic footwork movements for ten minutes at a time on each side. "He's found his root now; you can't take that away from him!" marveled David, proud of his student's accomplishments. To emphasize the Kua and lower limb movements, George demonstrates the footwork movements for Ba Men without the accompanying hand motions in the lower part of Figure 4. Zhan Zhuang, seen at the upper right part of Figure 4, is a basic yet demanding exercise of Taijiquan, including "Song Gong" and "Zhuang Gong". "Song Gong" aims to In one evening class, students learned to walk in a Taijiquan fashion: continuing with the spinal elongation and being careful not to press on the heels as the weight was distributed through the padded soles of the feet. Pulling from the Kua, students transfer their weight from the back to the front legs at angles of around 45 degrees, moving from one side of the school hall to the next. During a quick water break, a critically-minded beginner student, Luke, remarked in a jovial fashion: "Go to a primary school to learn to walk!" to which the ever-enthusiastic Rich replied with a beaming smile: "Where better to learn?!" These men were re-learning to walk in that cat-like manner of alertness, crispness and control as advised by Yang Chengfu a century ago. As mature adults, they are undergoing a process of physical re-education decades after their formal physical education as school pupils-a process that aims to remove mental, emotional and physical tension built up through work, study and stress in everyday life. This discussion has therefore offered a description and an illustration of how adult British students of one Taijiquan and Neigong organization re-educate their bodies through a focused on relaxed, controlled movements in order to develop an idealized Taijiquan-Neigong body that attempts to "hang the flesh off the bones". --- Conclusions and Implications All humans have different body shapes, sizes and abilities, with varying mobility and balance, and this is shaped by the diversity of body projects [50] available to us, from bodybuilding to jogging. Some adults in countries such as Britain are dedicating time and energy to develop a markedly different body through non-Western disciplines such as Yoga, Qigong and Taijiquan. In terms of the last two popular practices, this article has sought to address the research question: how, as adults, are Westerners learning to re-educate their varied, individual bodies through prolonged and intense Taijiquan and Neigong training? In order to explore this complex question, this article has drawn on linguistic data from an ongoing ethnographical and netnographical study of one branch of an international Taijiquan and Neigong association, the School of Internal Arts. This is a rather atypical Taijiquan association due to its emphasis on related Neigong theory and practice as connected to an interpretation of the core principles outlined in the early Yijinjing classic. The research design of ethnography and netnography allows for the exploration of this re-education due to the prolonged and intense nature of the pedagogical strategy taken by this School in its regular classes, courses, online lectures and Zoom classes. From the two years' fieldwork and online analysis, our initial finding was of the teacher and his students' pursuit of a gradually integrated Taijiquan body as connected with important loosening exercises and other Neigong practices , i.e., what we call the Taijiquan-Neigong body: a specific bodily ideal that the members of the School of Internal Arts strive towards. For reasons of space and to focus on the key aspect of the pedagogy , this article has examined specific exercises in line with the development of specific parts of the body as understood by a Chinese Daoist medical paradigm. This subtle or energetic body is primarily concerned with the inner aspects of the body such as the scapula and armpits rather than the shoulder and arm muscles, and the Kua, sacrum and tailbone as opposed to the buttocks or quadriceps, along with the center of the feet-all of which combine to sink the mass for martial arts development. Through the cultivation of control and expansion of the joints, fascia and muscles, the Taijiquan-Neigong practitioner is expected to develop a "strong, powerful body" in David's terms, which, as a by-product, is meant to be a healthy mind and body for daily living. The second main finding is that, beyond a form of physical re-education, Taijiquan and Neigong enable the development of both the mind and the body, especially through the combined emphasis on the principles of Song and Ting, as well as integrated concepts around "hanging the flesh from the bones" and "sinking the mass". Indeed, inspired by the philosophy of Yuasa [1,2] we highlighted the focus on mind-body integration through slow, meditative and repetitive movement can regarded as a form of self- cultivation, developing the human being in a rounded sense through cultivating habits and dispositions in terms of concentration, relaxation and emotional control. Following Spatz [33], we can see how humans can come to learn about themselves and the world through specific techniques repeated thousands of times in this intensive training, which is probably only suitable for adults willing to endure pain through immersion in their experience. The School of Internal Arts is an example of the voluntary physical re-education of adults following their earlier formal/compulsory physical education, lifelong habits, injuries, etc. Many of the members of the group come from backgrounds in Yoga, Qigong and the martial arts who are looking for something deeper, as the teacher David himself openly admitted to wanting when he found his own teacher and mentor, Malcolm. Through the Yijinjing principles and concepts such as Song and Ting come the systematic removal of habitual tension developed over time while loosening the body to become springy and alert. This could have many positive implications for wellbeing in later life, which could be explored in future interdisciplinary research projects. Third, expanding popular physical fitness and beauty ideals, this ideal Taijiquan-Neigong body differs considerably from the conventional Western modes of physical education and its chiefly European sports, games and physical exercises. As [51] has indicated, while some children thrive under this games-based education, others learn a sense of helplessness that is hard to remedy within a semester or school year. In fact, the removal of physical, emotional and mental tension may take years, if not decades. Adults come to Taijiquan for many different reasons such as spiritual growth, the quest for relaxation after work and the continuation of careers as martial artists-themes currently being exposed in a series of interviews with members of the School of Internal Arts. In fact, Taijiquan and Neigong are primarily taught to adults as a form of physical re-education. Following the premise that education and learning can be lifelong ambitions, we can argue the case for alternative pedagogies for mature and older adults as being of particular interest to physical educationalists-be they teachers, researchers or policy makers. To reiterate: as education is lifelong, so is physical education. Yet re-education is much harder than education, as years of tension and tightness in adult body-minds require years or even decades of dedicated practice. This is something to be considered by physical educationalists in terms of policy, practice and pedagogy. It is important to note that as an ethnographic study of one association in Europe, this research project does have some limitations in terms of its specific focus on a particular school branch in Britain with a relatively unusual interpretation of the Yijinjing and Taijiquan. This article is therefore not intended as a generalized reading of all Taijiquan, but one specific interpretation of some of the fundamental solo body conditioning exercises of a hybrid lineage of the Yang family. It is also based on data taken from ethnographic and netnographic fieldwork, while the one-to-one interviews are still being planned during the COVID-19 pandemic. With these limitations of this ongoing project in mind, other studies investigating the philosophy and practices of different kinds of Taijiquan schools would help shed light on how people are learning to use their bodies in new and different ways through a re-education process. This is an early output from what is planned to be a five-year ethnographic study of the School of Internal Arts. The specific theory and practice of Neigong should also be explored in its own right. Future research might consider the role of core texts and elements of Chinese culture such as the Daodejing, Chinese astrology and medicine, which influence the interactions and practices of the group. For instance, some of the core members of the School have undertaken courses in Chinese medicine and acupuncture, and many of these students are now offering astrological services to their classmates, showing a Chinese cosmological view of the world, but demonstrated by non-ethnic Chinese people . We are planning a larger project to investigate the transmission of specific elements of Chinese culture outside of mainland China in countries such as Britain, where the dissemination of knowledge is often via online YouTube channels and podcasts as led by a new generation of reputed, mobile and charismatic instructors. Moreover, future research can consider broader approaches to applying Eastern philosophical principles in Western pedagogical contexts that move beyond classical ideas of the Yijinjing and Taijiquan in Britain. Continuing from Yuasa's [1,2] overarching perspective on self-cultivation, [52] notes that, despite the great variety of Eastern models and cultures from Asia, there is a general interest in training the person in a holistic sense and over the lifespan . This has been raised by Lee [53] in his empirical research on children's formal physical education, which noted the different approach taken in Western education such as focusing on the dominant hand when learning the overhand throw. Research on handedness, balance between the sides of the body and elements of the anatomy in Eastern martial arts would therefore be pertinent in comparison with those of the West fencing, with its focus on the dominant side). This could accompany the exploration of philosophical ideals in other Eastern movement forms such as Yoga, Qigong and meditation which continue to flourish in Western contexts, albeit in often hybridized and commercialized formats [54]. --- Data Availability Statement: The data presented in this study are available on request from the corresponding author. The data are not publicly available due to the ethical agreement with the Cardiff Metropolitan University Social Sciences Ethics Panel to keep the data under George Jennings' personal OneDrive account, which is not accessible to the wider public. --- Author Contributions: Conceptualization, G.J. and X.M.; methodology, G.J. and X.M.; formal analysis, G.J. and X.M.; investigation, G.J. and X.M.; resources, X.M. and G.J.; data curation, G.J. and X.M.; writing-original draft preparation, G.J. and X.M.; writing-review and editing, X.M. and G.J.; project administration, X.M. and G.J.; funding acquisition, X.M. All authors have read and agreed to the published version of the manuscript. Funding: This research was funded by Hebei Social Science Fund, grant number HB19TY001. --- Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Ethics Committee of Cardiff Metropolitan University . Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. ---

In a globalized, media-driven society, people are being exposed to different cultural and philosophical ideas. In Europe, the School of Internal Arts (pseudonym) follows key principles of the ancient Chinese text The Yijinjing (The Muscle-Tendon Change Classic) "Skeleton up, flesh down", in its online and offline pedagogy. This article draws on an ongoing ethnographic, netnographic and cross-cultural investigation of the transmission of knowledge in this atypical association that combines Taijiquan with a range of practices such as Qigong, body loosening exercises and meditation. Exploring the ideal body cultivated by the students, we describe and illustrate key (and often overlooked) body areas-namely the spine, scapula, Kua and feet, which are continually worked on in the School of Internal Arts' exercise-based pedagogy. We argue that Neigong and Taijiquan, rather than being forms of physical education, are vehicles for adult physical re-education. This re-education offers space in which mind-body tension built over the life course are systematically released through specific forms of attentive, meditative exercise to lay the foundations for a strong, powerful body for martial artistry and health.

Introduction Y oung men who have sex with men have a substantially elevated burden of human immunodeficiency virus relative to young men who have sex with women only . 1 YMSM accounted for 95% of estimated HIV diagnoses among adolescents between 13 and 24 years and for 27% of new HIV diagnoses among MSM in the United States in 2015. 1 There are also racial and ethnic disparities in the burden of HIV among MSM. 2,3 The disproportionate rate of HIV among YMSM relative to YMSW is explained partly by biological 4,5 effects that increase the risk of HIV acquisition for YMSM and by the high prevalence of HIV among the MSM with whom YMSM partner. 2,6,7 Stigma 8 and other structural factors, such as the inclusivity of sex education, may also play a role. Prior evidence suggests that young men who have sex with both men and women may also have different HIV risk and risk behaviors than young men who have sex with men only . 9,10 Understanding differences by sexual behavior groups may reveal key areas for interventions in youth. Despite the disproportionate burden of HIV among YMSM, there is little information on whether HIV education is reaching YMSM or on YMSM sexual risk behaviors 11,12 ; most evidence on MSM sexual behaviors is from adults 13,14 and most evidence on sex education is focused on changes in sexual risk behaviors in the general population. Schools are an ideal setting for sex education programs because school-based education has the ability to reach most adolescents. Evidence indicates that comprehensive sex education in schools can reduce a range of sexual risk behaviors, including delaying age of first sex, reducing the number of sexual partners, and increasing condom use. 15,16 A 2001 study also indicated that sex education that included sexual minorities was associated with greater reductions in sexual risk behaviors among sexual minority adolescents. 17 Even so, only 24% of U.S. public high schools reported using curricula or supplementary sex education materials relevant to sexual minorities in 2014. 18 When schoolbased sex education does not reach YMSM, they may learn about sex from sexually explicit material or other sources that do not emphasize HIV prevention. 19 Understanding whether the HIV education and sexual behaviors of YMSM differ from those of YMSW, and the extent to which HIV education is associated with sexual risk behaviors among YMSM, is important for informing approaches to sex education that effectively reduce transmission of HIV and other sexually transmitted infections to adolescents. 20 The landscape for sex education and HIV prevention among YMSM has changed rapidly in recent years and since the last study on HIV education and sexual risk behaviors among sexual minority adolescents was published in 2001. 17 Life-prolonging HIV treatment has been available for as long as many YMSM have been alive. Newly diagnosed HIV infections are declining, which may change perceptions about HIV transmission. 1 There have also been cultural changes, such as increased support for sexual minority rights, that may affect sex education. 21,22 At the same time, mobile phones are changing sexual culture and potentially sexual risk through applications that facilitate sexual encounters, while also promoting access to information on the Internet. There have also been advances in HIV prevention, with recent studies demonstrating that daily oral pre-exposure prophylaxis can prevent HIV infections effectively and safely. [23][24][25][26][27] This changing landscape suggests a need for up-to-date information on the sex education and sexual risk behaviors of YMSM to address the continuing epidemic. We chose to focus on HIV education as a particularly important component of sex education for YMSM. We investigated two main questions: Do self-reported school-based HIV education or sexual risk behaviors differ among YMSM relative to YMSW and is school-based HIV education associated with reduced sexual risk behaviors among YMSM? --- Methods --- Sample We used state Youth Risk Behavior Surveillance System data from all 13 states with Youth Risk Behavior Surveys that inquired about sex of sexual contacts and about HIV education in 2011 and/or 2013 and had weighted data. 28 While 2015 state YRBS data had been released at the time of the study, the 2015 YRBS wave did not include questions on HIV education. The YRBS also has a nationally representative survey, but the 2011 and 2013 national YRBS did not include data on sex of sexual contacts. Students from states in the Northeast, Southeast, Midwest, and Southwest regions of the United States are included in the sample . YRBS data from each state were weighted to be representative of high school students in the state. For states that had data on sex of sexual contacts and on HIV education in both 2011 and 2013, we pooled the data from two years to increase the sample size. To account for pooling two years of data, we divided sample weights by two. For states that collected the relevant data in only one of the two study years, we included the data only for that year. The data that we combined from multiple states are representative of the students in the included states. 29 We restricted the analysis to students who had been sexually active to assess sexual risk behaviors. We excluded students who reported ever being forced to have sex because we could not distinguish whether self-reported sexual risk behaviors pertained to forced or consensual sex, and we would not expect students to be able to make their own decisions about sexual risk behaviors in the context of forced sex. We defined two subpopulations of students to conduct the analyses: students who had any lifetime sexual partner and students who had two or more lifetime partners, a population defined to make comparisons between YMSW and YMSMW, who by definition had a least one male and one female partner. --- Exposure In our analyses of the relationships between sex of sexual contacts and the outcomes of HIV education and sexual risk behaviors, the exposure of interest was whether students were YMSM. We categorized males as YMSM if they reported sexual behavior with males only or with males and females in response to the question ''During your life, with whom have you had sexual contact?'' Based on the same question, we further divided YMSM into subgroups of YMSMO and YMSMW to assess risk behaviors, comparing YMSMO with YMSW with any lifetime sex partner and comparing YMSMW with YMSW with two or more lifetime sex partners. We categorized males as YMSW if they reported sexual behavior with females only. Students who indicated that they had never had sex were excluded from the analysis. Connecticut x x x x x x x x x Delaware x x x x x x x x x x Florida x x x x x x Hawaii x x x x x x x x x x Illinois x x x x x x x x x x Kentucky x x x x x Maine x x x x x Michigan x x x x x x x x x x New Hampshire x x x x x x x x x New Mexico x x x x x Ohio x x x x x x x x x Rhode Island x x x x x x x x x x Wisconsin x x x x x x x x x x In our analyses of the relationship between HIV education and sexual risk behaviors, the exposures of interest were whether students reported receiving HIV education in school as well as a term interacting HIV education and being YMSM. Students could answer ''yes,'' ''no,'' or ''not sure'' in response to the question, ''Have you ever been taught about AIDS or HIV infection in school?'' We coded this question as a binary variable indicating whether or not students responded ''yes.'' --- Outcomes We first assessed the outcome of learning about HIV in school. We then assessed sexual risk behavior outcomes, including whether students had four or more lifetime sexual partners, whether students had three or more sexual partners in the past three months, and condom use at last sex. We ascertained the number of sexual partners based on answers to the questions, ''During your life, with how many people have you had sexual intercourse'' and ''during the past three months, with how many people did you have sexual intercourse?'' Based on student answers to these questions, we created binary variables indicating whether students surpassed four or more lifetime partners or three or more partners in the past three months, with cut points based on prior YRBS analyses of sexual behavior. 30,31 Students reported on condom use in response to the question, ''The last time you had sexual intercourse, did you or your partner use a condom?'' For YMSMW, we did not have data on the number of partners of each sex or on whether condom use at last sex pertained to a male or female partner. In all analyses, we used linearized standard errors that accounted for the multistage sampling design. We first described the sample, adjusting for the sampling design with linearized standard errors as recommended for the YRBS. 28 We then assessed whether HIV education and risk behaviors differed between YMSM and YMSMO relative to YMSW among students with any lifetime sexual partner, or between YMSMW and YMSW among students who had two or more lifetime sex partners. For each of these analyses, we estimated multiple logistic regression models controlling for age, race/ ethnicity, state, and year. The YRBS does not include information on individual student socioeconomic status. To highlight potentially intersecting disparities, we also reported information on racial and ethnic differences in HIV education and sexual risk behaviors. Next, we assessed the relationship between HIV education and sexual risk behaviors through an additional set of logistic regression analyses. We assessed both HIV education and a term interacting HIV education with being YMSM to estimate how the relationship between HIV education and sexual risk behaviors among YMSM compared to that of the general population of male high school students. We again controlled for age, race/ethnicity, state, and year and estimated linearized standard errors that accounted for the multistage sampling design. For this analysis, we did not further divide YMSM into YMSMO and YMSMW because we had limited power due to the small sample sizes of the subgroups. --- Ethics statement The Johns Hopkins Bloomberg School of Public Health Institutional Review Board determined that this study was ex-empt in decision FWA #00000287. We used only deidentified, delinked data. The Centers for Disease Control and Prevention IRB approves the national YRBS and determined that a YRBS conducted by a state is public health practice rather than research. Decisions to seek IRB approval, and whether to seek parental permission, are based on state procedures. Students completed the anonymous questionnaires in classroom settings. --- Results A total of 30,617 adolescent males participated in the 2011 and 2013 YRBS in the 13 states that collected information on both sex of sexual contacts and HIV education. Of these males, 17,606 reported ever having sex, 844 were excluded because they reported having been forced to have sex, and 390 were excluded because they did not report their age or race. Of 16,372 participants remaining, 15,337 reported sex exclusively with females, 549 reported sex exclusively with males, and 486 reported sex with both males and females. We describe the study population by sex of sexual contacts in Table 2. The sample was predominantly non-Hispanic White, with AMs of 62% of YMSM and 66% of YMSW reporting that they were White. Approximately half of YMSM and YMSW were aged 17 or older and half were aged 16 or younger. We summarize differences in HIV education and in sexual risk behaviors among YMSM, YMSMO, and YMSMW relative to YMSW in Table 3. Relative to 90% of YMSW, just 84% of YMSM reported learning about HIV in school . Lower rates of HIV education were particularly driven by YMSMW, with 81% of YMSMW reporting receiving HIV The N for each analysis differs based on the states and years in which the Youth Risk Behavior Surveys included each outcome question. We conducted logistic regression analyses controlling for race/ethnicity, age, state, and year and using Centers for Disease Control and Prevention-specified weights to make data representative of high school students in each state. HIV education and sexual risk behaviors for YMSMW were computed relative to YMSW with two or more lifetime sexual partners because YMSMW must have had at least two sex partners to have had sexual contact with both sexes. *P < 0.1, **P < 0.05, ***P < 0.01. AOR, adjusted odds ratio; YMSW, young men who have sex exclusively with women; YMSM, young men who have sex with men; YMSMO, young men who have had sex with men only; YMSMW, young men who have sex with men and women; HIV, human immunodeficiency virus. --- 134 RAIFMAN ET AL. education in school . YMSMW had greater odds of having three or more sexual partners in the past three months , with 26% of YMSMW reporting three or more partners relative to 9% of YMSW who had two or more lifetime sex partners. Less than half of YMSM, including both YMSMO and YMSMW, reported condom use at last sex, relative to 72% of YMSW . There was not a statistically significant difference in the odds of having four or more lifetime partners between YMSMW and YMSW with two or more lifetime sex partners , while YMSMO had lower odds of having four or more lifetime sex partners . Relative to non-Hispanic White students, students who were non-Hispanic Black, Hispanic, and of other race or ethnicity were less likely to report HIV education and more likely to report four or more lifetime sexual partners and three or more sex partners in the past three months. There were no racial or ethnic differences in condom use at last sex. We summarize the results of the relationship between school-based HIV education and sexual risk behaviors in Table 4. Self-reported school-based HIV education was associated with significant reductions in the odds of male adolescents having four or more lifetime sexual partners and having three or more sexual partners in the past three months , as well as with significantly increased odds of condom use among adolescent males . School-based HIV education was also associated with significant further reductions in the odds of YMSM having four or more lifetime sexual partners and in having three or more sexual partners in the past three months and with significantly increased odds of using a condom at last sex . Discussion YMSM reported lower rates of school-based HIV education than YMSW. YMSM also reported more risky sexual behaviors, including lower condom use at last sex; less than half of YMSM reported using a condom at last sex, relative to 72% of YMSW. In addition to lower condom use, YMSMW had greater odds of having three or more sex partners in the past three months. There were also racial disparities in HIV education and in numbers of sexual partners ever and in the past three months. Intersectional disparities affecting racial or ethnic minorities and YMSM may contribute to particularly high rates of HIV among racial and ethnic minority YMSM. 1,2 Riskier sexual behaviors could exacerbate biological and sexual The N for each analysis differs based on the states and years in which the Youth Risk Behavior Surveys included each outcome question. We conducted logistic regression analyses controlling for race/ethnicity, age, state, and year and using Centers for Disease Control and Prevention-specified weights to make data representative of high school students in each state. We estimated interaction terms for HIV education and YMSM; these estimates reflect additional relationships between HIV education and sexual risk behaviors among YMSM, in addition to the relationship between HIV education and sexual risk behaviors in the general population of young men. **P < 0.05, ***P < 0.01. YMSM, young men who have sex with men; YMSW, young men who have sex exclusively with women; HIV, human immunodeficiency virus. network factors that increase the risk of HIV transmission among YMSM. School-based HIV education was associated with significantly reduced sexual risk behaviors among all adolescent males, and with additional significant reductions in sexual risk behaviors among YMSM. Lower reported HIV education among YMSM, particularly YMSMW, relative to YMSW may reflect that sex education is often not inclusive of sexual minority students. 18 These findings are consistent with prior research indicating that YMSM do not feel that sex education materials designed for the general population are pertinent to their needs. 17,32,33 The CDC's School Health Profiles report indicates that just 24% of schools reported providing curricula or supplementary material on safe sex for sexual minorities. 18 Lower levels of learning about HIV in school among YMSM may partly explain lower condom use among YMSMO and YMSMW and greater numbers of sexual partners among YMSMW. Other factors, such as social norms or different ways of meeting partners, may also contribute to differences between YMSM and YMSW sexual risk behaviors. Our findings that YMSM were less likely to report HIV education and that receiving HIV education was associated with reduced sexual risk behaviors among YMSM reflect a need to better ensure that HIV education reaches YMSM. There is a large body of evidence supporting the efficacy of schoolbased sex education programs for reducing sexual risk behaviors, 15,16,34,35 and school-based programs have the advantage of reaching most children. 32 Our findings are also consistent with a 2001 study indicating that HIV education was associated with reduced sexual risk behaviors among sexual minorities in Massachusetts. 17 Given the substantially elevated burden of HIV and other STIs among YMSM, it is especially important to reach YMSM with sex education that includes information on HIV and STI transmission and prevention, including with PrEP, in the context of sex between two males. 36 Including information on YMSM sexual health in sex education classes may also normalize same-sex sexual behavior and reduce stigma that can come from excluding marginalized populations. 37 Historically, sex education and sexual orientation have been highly politicized. 38,39 Seven states currently ban positive discussion of same-sex sexual behavior or orientation by school teachers or staff members, 40 and three states require inclusion of negative information about sexual minorities in sex education. 41 Efforts to make sex education more inclusive of sexual minorities are likely to face opposition. 42 Despite the challenges, nine states mandate that sex education be inclusive of sexual minorities without mandating negative coverage, 41 demonstrating that inclusive sex education is feasible. --- Limitations Our study has some limitations but also provides important and novel evidence on differences in YMSM HIV education and sexual risk behaviors. Limitations include that there may be unmeasured differences in student or school characteristics that affect both exposure to HIV education and sexual risk behaviors. For instance, the YRBSS data that we used did not include a measure of socioeconomic status. The data did not include detailed information on HIV education, including whether students learned about HIV prevention or the class in which students learned about HIV. The data also did not include detailed descriptions of sexual behaviors. For adolescent males with both male and female partners, we could not assess whether the number of total partners, partners within the past three months, or condom use at last sex pertained to male or female partners; although the differences we found in HIV education and in sexual risk behaviors among YMSM are relevant regardless of whether sex partners were male or female. The generalizability of the study is also limited because only 13 of 50 states collected data on both the sex of adolescent sexual contacts and HIV education; the study results are representative in these states, but not the entire country. We also excluded participants who reported ever being forced to engage in sex because we could not distinguish whether sexual risk behaviors reported by these students occurred in the context of forced or consensual sexual relationships. Consistent with recent findings from the 2015 nationally representative YRBS, 30 YMSM reported elevated rates of being forced to have sexual intercourse. More research is necessary to determine why YMSM experience elevated rates of forced intercourse and to inform interventions to reduce forced sexual intercourse among YMSM. While these are significant limitations, evidence that YMSM report lower levels of HIV education and that HIV education was significantly associated with reduced sexual risk behaviors among YMSM is important given the high and rising rates of HIV among YMSM. Our results suggest that there may be important differences in HIV education and sexual risk behaviors between YMSM and YMSW. --- Conclusion Although YMSM made up more than 95% of HIV diagnoses among individuals between the ages of 13 and 24 years in 2015, 1 YMSM reported being less likely to receive HIV education and more likely to engage in sexual risk behaviors. YMSM had particularly lower odds of reporting condom use at last sex, an alarming finding given the high and increasing rates of HIV transmission among YMSM. 1 HIV education was associated with reduced sexual risk behaviors among all students, and with significant additional reductions in sexual risk behaviors among YMSM. Reaching YMSM with school-based sex education that incorporates relevant information on condom use, PrEP, and elevated HIV risk among YMSM could play an important role in reducing sexual risk behaviors and reducing HIV transmission. --- 'x'' indicates that states collected data on the variable in the year 2011 or 2013. HIV, human immunodeficiency virus. --- Author Disclosure Statement No competing financial interests exist. --- 136 RAIFMAN ET AL.

Purpose: Men who have sex with men (MSM) have nearly 80 times the lifetime risk of human immunodeficiency virus (HIV) relative to men who have sex with women only (MSW), and young MSM (YMSM) accounted for 95% of estimated HIV diagnoses among adolescents between 13 and 24 years in 2015. We aimed to evaluate HIV education and sexual risk behaviors among YMSM relative to young MSW (YMSW) and to evaluate the relationship between HIV education and YMSM sexual risk behaviors. Methods: We used Youth Risk Behavior Surveillance System data from 13 states that collected information on sex of sexual contacts and on HIV education in 2011 and/or 2013. We assessed HIV education, number of sexual partners ever and in the past three months, and condom use at last sex in logistic regression analyses controlling for age, race/ethnicity, state, and year. Results: YMSM were less likely to report school-based HIV education and more likely to report sexual risk behaviors relative to YMSW. HIV education was associated with reduced sexual risk behaviors among all students and with significant additional reductions in sexual risk behaviors among YMSM. Conclusion: There is a need for HIV education programs to reach YMSM, who are at increased risk of HIV.

Introduction In recent years, sports stars had been gaining much attention from the public. Especially during the Olympic games, gold medalists were often on the top of Weibo's hotlist and were widely sought after by the country's people. It was due to the rising in living standards and the importance of sport in people's minds, as well as the widespread dissemination of their images in the mass media. However, the public's perception of a gold medal athlete was replaced by a media image constructed by the media and whose influence was created through communication [1] . Athlete media image was a typical type of media image, meaning the image of an athlete that is shaped and communicated through the media [2]. Nowadays, as the 'super producer' of media topics, the media presentation of gold medal athletes had become an important part of people's social and spiritual culture. With widespread attention from the media and audiences, this particular media image of the gold medalist had also attracted a great deal of academic attention. On the one hand, this particular media image could be seen as a mirror image of the times. Its shifts also reflect China's mass media changes and even the changes in China's economy, politics, and people's consciousness. In addition, with the rapid development of the media industry, the media image of gold medal athletes as an important communication medium also influences contemporary social identity, the public's sports culture perception, behavior, and even the image of the country. Therefore, this study summarized the the changing trends in the media image of gold medal athletes and the possible factors including communication medium and audience. --- Trends --- The Diversification of Athletes' Media Image Most of the audience's understanding of professional athletes came from the media reports. The impression in the audience's consciousness was formed by the information spread by the media. It was believed that the media image of athletes now involves various dimensions, which was the embodiment of the mainstream values and aesthetic orientation of different eras [3]. With the development of the mass media and the sports market, the media image of professional athletes presents two significant changes diversification and commercialization. In the past, the media attention on athletes was mainly focused on their accomplishments, such as revealing their rankings. Furthermore, male athletes tended to receive much more media attention compared with females. However, with the rise of social media and a national emphasis on humanism in recent years, media portrayals of athletes had been more focused on presenting the athletes' multi-layered character and attributes, which could be reflected by the changes in the media presentation of female athletes. Firstly, there had been an increase in the frequency of female athlete media presentations. Female power had become mainstream. In Fu's study of the female athletes in 'people's public' from 2008 to 2015, the number of reports on the female athlete in the long-term was lower than the one of males. It showed that female athletes were marginalized in China's mass media, which makes the one-sided and single media content more prominent [4]. Due to the long-term "stereotype" of women in society and the deviation of some female athletes' self-positioning, the image of female athletes was solidified in the sports reports with female athletes as the leading role [5]. The image of the female athlete was endowed with a high degree of gendered characteristics by the media, presenting the traditional female stereotype, and placing it in the traditional female role of "gentle" and "weak". In the mainstream concept of society, male sports culture was still the mainstream, and female athletes could not get rid of their final image of returning to family responsibility. With the increase in the number of female athletes and the modernization of the sports field, there had been a breakthrough in the image of female athletes. Among them, Li Na was a representative example. As an athlete who was mainly promoted as a female national hero, Li's media image highlighted her health as wise, international, and stylish. Although she was questioned by the media and the masses for her free personality and bold speech, she broke the stereotype of previous tennis players, showing a different image of a female athlete of herself, which was different from the traditional one [6]. Secondly, the portrayal of multidimensional personalities enriches the characterization of the athletes. Mann et al. contribute a scale that had seven dimensions of celebrity image by analyzing the media content of film and sports stars: social and ethical responsibility, life and style, professional capabilities, perspective towards celebrity's profession, orientation towards fans, attractive physique, and public image. They believe that all these factors were important in today's celebrities [8]. The Rio Olympics could be destined to be a sign of the change in China's Olympic culture. According to the relevant media content of Fu Yuanhui, Zhang Guowei, Liang Xinping, and the women's volleyball players, the Chinese athletes had largely overturned the fixed image of them, and the personalized label had been becoming more obvious and accepted by the public [9]. The Olympic spirit shown by the media image of these young generations of athletes had changed the "gold medal only" ethos in Chinese public opinion. This change was more significant in those famous medal athletes. Take Lina as an example. Cheng states that it was Li Na herself, her management team, and the commercial media that created a new media image of athletes with ideas, personalities, and independent consciousness for the public. In the media content of Lina's retirement, network sports media not only tracked the progress of Li's retirement and integrated a large number of historical data about Li's career, but also richly showed Li's family background behind her achievement, fighting experience, and love story. They even reproduced comments from different media to ensure multiple views coexist. Cheng regards this as an advance in online media coverage [10]. --- The Commercialization of Athletes' Media Image Commercialization was growing throughout the sports industry, and the entertainment orientation of media on the topic of athletes had become common as the image of athletes was the reflection of the sports culture of an era. The growing public demand for entertainment consumption had prompted the media to track down professional star athletes, many of whom often go beyond sports or political propaganda. More reports changed from Sports News to Entertainment News. As Guo claims, among the messages on famous athletes such as world swimming champion Sun Yang and Guo Jingjing, the number of entertainment news was far larger than traditional sports news [11]. In traditional mass media content, sports stars not only remind the audience of teamwork and fair competition but also largely represent national symbols such as playing the national anthem and raising the national flag [12]. Xu took the example of Rong Guotuan as an example to illustrate the political significance of athletes winning the championship. Rong Guo Tuan's victory was even praised by the national premier and mentioned during the national holiday, while the process of the game was considered to be less important in the media [13]. However, with the development of social media, the trend toward the commercialization of the sports industry had become more apparent. The media hopes that well-known athletes will be included in the "Internet celebrities" category and spread various information within the framework of sports reporting and entertainment, to attract the public's attention. For example, the market officials of QuanMin TV said that when they choose the Olympic stars to cooperate with, they first require these sports stars to have their own "star features", they will choose sports stars that were interactive and had distinct personalities [12] . Famous athletes such as Liu Guoliang and Zhang Jike had also been Internet celebrities. Among them, Zhang had more than 8 million followers on Weibo, which Xu believes had a positive effect on promoting table tennis but weakens their image as athletes [14]. In the process of shaping the image of athletes, the network media also paid excessive attention to entertainment and lack of objectivity and rational reporting. The media content about professional athletes was mixed with much negative information. To some extent, the negative news greatly meets the needs of the audience for entertainment and meets the needs of some audiences nowadays. At the same time, this was harmful to the presentation of athletes' values. Therefore, it was particularly important to play the positive role of network media in shaping the sports image of athletes in information communication. --- 3. --- Factors --- Richer Communication Medium Traditional media such as newspapers, outside, communication, radio, TVs, and network television were once the primary platforms for athlete media images [15]. With the development of Internet technology, the emergence of increasingly new media platforms such as Weibo and Tik Tok had brought a certain impact on traditional news and opportunities [16]. The development of multiple media platforms had also provided a platform for the presentation of athletes' media images and was the reason for their diversification and commercialization. For example, traditional television was a one-way medium. However, with the rapid development of Internet technology, the use of Internet communication on computers had made it possible to provide personalized programs [17]. Different media had different communication characteristics, which in turn had contributed to the classification of the image of athletes. For example, in traditional media such as television and radio, athletes mainly present their image by their performance on the field of play. While in fragmented information platforms such as Tik Tok, athletes' interviews or daily life were more often shown and focused on, and on platforms such as B-site, athletes share their knowledge of fitness skills. --- Diverse Communication Subjects The differences between the new media environment and the traditional media era were mainly reflected in the fact that the communication subjects had changed from one-to-many to many-to-many. In the traditional media era, it was difficult to interchange roles between the media and the recipient, and it was often a single message sent by the communicator. However, with the advent of the new media era, the subject and the audience of the athlete's media image had gradually shifted from oppositional to interchangeable. They could be both the subject of communication and the subject of reception. In the new media era, the characteristic of "everyone was the subject of communication" makes the subjects of communication more diversified. Everyone was an information disseminator. In addition to some official platforms, some self-published blogs, athletes, and even individuals who re-tweet content on Weibo had become the disseminators of their media images. For example, Gu Ailing, world champion of women's freestyle skiing at this year's Beijing Winter Olympics, had more than six million followers on microblog alone. The different preferences of individual communicators also explain the trend of diversified communication of athletes' media images to a certain extent. As an important media of sports communication, official media played a vital role at any time. For example, CCTV Sports Channel had become an important platform for people to watch sports events in the era of traditional media. In the era of Internet new media development, people could pick up their mobile phones at any time to watch live replays of events or directly open the microblog of CCTV Sports to get the latest sports information. Traditional media were developing rapidly in today's society, and media convergence significantly impacts news dissemination. Convergence media was a concept that integrates the advantages of traditional media and new media. For example, during the 2018 Pyeongchang Winter Olympic Games, CCTV and Xinhua News Agency used high-tech technologies to broadcast sports events, giving full play to the advantages of convergence media to bring an unprecedented interactive experience to the audience [18]. --- Broader Audience The media portrayal of athletes is heavily influenced by their audience. With the growth of China's economy and the popularity of the Internet, the audience had changed considerably, which was also one of the reasons for the transformation of athletes' media images. Starting from McGuire's theoretical paradigm and combined with the changing situation of integrated media in the new era, it found that the audience of the media had changed a lot from 2000 to 2020, and the range of the social media's age had become wider. To sum up, the specific reasons were as follows [19]. Firstly, the ways of media development were changing now, and the audience's age range had become wider. With the popularity of smartphones and 4G networks, live streaming platforms like TikTok began to rise and soon became popular throughout China. It had also led to the gradual change of the media from TV to smartphones and computers, leading to a wider age range. Then it meant that people from young to old could find content suitable for them on short video platforms, thus increasing the scope of the whole audience. Moreover, because of the fast times, many people, especially the young people under stress, hardly had a whole period to watch the overall process. Compared with the paper media, they may be more willing to watch the short video platform to shorten the reading time. According to the Us Media Audience Statistics Report, as of December 2020, traditional media, including television and radio, were no longer the most widely available media among American adults, as audience numbers continue to decline. Instead, streaming had the broadest audience. Recalling a report from the previous year, radio and television still had an overwhelmingly high voice among adults, even as the audience share of traditional media in the United States was shrinking. By June 2020, weekly hit rates for all digital media types had increased to some extent, while traditional media in the United States had shrunk slightly. In the current analysis, streaming video was the most viewed and most-watched form of media, with about 80 percent of American adults watching streaming video every week. In addition, about 78.9 percent of American adults used social media at least once a week. It meant that streaming not only outstrips traditional American television, but social media outperforms terrestrial radio by 0.8% [20]. The age diversity of users of social media and the fragmented nature of its information had, to some extent, contributed to the categorization of the presentation of athletes' media images, which was the presentation of content that was specific to different age groups. Secondly, there was a gradual gender balance in the audience for athletes' media images. In the past, social media platforms were more likely to target men, especially in sports, because at that time, men had a higher social status. At the same time, women were considered more appendages of men, so most TV programs were designed for men. Nowadays, with the development of the time, women's social status had improved, becoming the main force of consumption. In addition, the appearance of female sports stars such as Gu Ailing and Fu Yuanhui led more women to pay attention to and began to try sports, so the audience of media had gradually added female factors and images of masculinity [21]. Thirdly, due to the development of social media, print media status may not be as high as before. It also represented a media reduced barriers to entry. In the past, only 30 s and 40 s intellectuals may read news articles and reports, and now more people were using tablets, laptops, and smartphones to catch up on what was going on. Newspapers should make use of the advantages of the Internet and mobile media, taking advantage of the social, retrieval, and big data functions of new media, producing content suitable for cross-media, and creating digital platforms. It meant as long as you could see could hear, all the people could share the news and read, lowering the threshold of the reading audience so that the audience could understand the news and other topics even if they were not so highly educated [22]. So, the whole audience's age range will be wider, and participation will be higher. That was why compared with the social media from 2000, the media today could be much broader in 2020, moving from a limited audience to universal participation. --- 4. --- Conclusion With the public's increasing interest in sporting events and the widespread availability of digital media, gold medal athletes were being presented to a wider audience through mass media. As a specific type of media image, the media image of the athlete was considered to be largely associated with social change. It could reflect changes in contemporary media culture and the characteristics of mass media communication. This paper discussed the changes in the media representation of athletes after 2000 and analyses the reasons for them through three aspects: richer communication medium, diverse communication subjects, and a broader audience. The media presentation of athletes was overall diversified and commercialized. With the change of the sports culture, the personality of the athletes became highlighted in the media, and the stereotyped image of athletes, especially female athletes, had been largely replaced by diversified ones. Besides, with the marketization of the media and sports flew, athletes' image-building process in the media should be commercialized instead of completely led by political purposes. However, although the media presentation of athletes had evolved considerably, there were still some problems in the communication process. Firstly, the stereotypes about athletes had not been eliminated. Besides, some new problems had emerged, such as the excessive commercialization leading to a distorted image of athletes, which could be harmful to their careers, and too much unconfirmed negative information that could mislead viewers and hurt teenagers. Therefore, both the public and athletes should actively respond to the effects and problems of public opinion through media. Identifying and correcting problems in the communication would better promote the spread and development of Chinese sporting culture and disseminate athletes' media images. In addition, the Olympics had positioned itself as an important form of education, providing realistic and vivid models to young people around the world to achieve educational results, which provides a basic idea for the media to shape the public image of well-known athletes. Showcasing athletes in this direction helped the media properly portray athletes as public icons. In the modern media era, with consumers' rising subjective awareness, the constraints of their communication process could no longer be overlooked. First, non-professional topics such as athlete privacy and certain statements were frequently over-emphasized with the increase in information and coverage, as well as the diverse interests of viewers, This excessive attention leads to the dissemination of entertaining or commercialized information, which in turn leads to the neglect of the authenticity of the athletes themselves [23]. In addition, the diversification of communication media, in addition to official reports such as television news, personal media accounts, or the athletes' media accounts were also important ways of communicating their media images. Besides their performance on the field of play, athletes' private behavior and activities also attract a great deal of attention from their audiences, which places a higher demand on their ethics. Therefore, the mass media should take up the corresponding responsibility when shaping the media image of athletes, focusing on shaping their positive image of enterprising and challenging work. At the same time, the mass media should strengthen their control over the shaping content, so that their idolized communication could play a more positive role, set a positive example for the public, and transmit positive energy to society [4]. Secondly, athletes themselves should be clear about their social responsibilities and convey a healthy and positive media image to their audiences to enhance their image and social recognition. At the same time, audiences themselves should have a sense of social responsibility, constantly improve their media literacy, screen relevant reports, and choose positive content for dissemination. The study still had some limitations. Firstly, although this study explores the changes in the media representation of athletes in some aspects generally, there were many places where in-depth research could be carried out as the media image of the character was a complex topic. Besides, it would also be valuable to discuss some of the features and issues in the current media representations of athletes that were identified in this study. For example, a focused analysis of the image of athletes on particular social media platforms or mainstream media could provide a more concrete answer to how and why images are changing. In the future, researchers could address the shortcomings of the current athlete media presentation, for example, by examining the text and finding solutions to the negative portrayal of athletes. In addition, subsequent research could address the current changes that athletes' media images could more easily impact youth audiences. Social learning or planned behavior theories could examine how athletes' media images influence the daily behavior of youth.

With the media explosion of Ailing Gu and other athletes at the Beijing Winter Olympics, the topic of the media image of gold medal athletes had attracted much academic attention again. The current study reviewed the media image of gold medalists from two aspects, the developing trends and the factors including communication medium, subjects, and audience. The results showed that the media image of athletes showed a trend of diversified and commercialized content, which was closely related to the more diverse communication platforms, rich communication subjects, and wide audience in the new media era. Communicators' message filter, a strong sense of social responsibility for the athletes, and a better media literate of the audience were necessary to cope with the problems that appear during its development. These findings were critical for better understanding China's economic and social development and examining ideas and methods for improving public perception of sports culture.

Introduction Social determinants of health , including food insecurity, housing instability, and financial hardship, are common in the United States, 1 disproportionately impact vulnerable populations, and are associated with poor health outcomes. One in 8 US households are food insecure, 2 0.2% of US adults are homeless, 3 and 12% are living in poverty. 4 Food, housing, and financial insecurities are more common among women, African Americans, younger adults, and those with lower education or chronic conditions. [5][6][7][8][9] Food insecurity is independently associated with obesity, 10 peripheral artery disease, 11 hypertension, 12 hyperlipidemia, 12 diabetes, 13 medication underuse, 14 and overall poor health. [15][16][17] Both food insecurity and housing instability are associated with sleep disorders, 18,19 social isolation, 20 cardiovascular disease, 7 and poor overall physical and mental health. 18,[21][22][23] There is extensive evidence of the negative effects of financial hardship and poverty on health and access to care. 24 Poor health outcomes, financial hardship, and food insecurity are worse in rural areas than urban areas, [25][26][27] although mechanisms differ. Poor functional capacity is a common physical limitation among the chronically ill and a major risk factor for mortality. [28][29][30] Exercise capacity, a measure of functional capacity, is the maximum sustainable amount of physical exertion. It is typically measured by the amount of oxygen consumed during maximal exercise, often presented in metabolic equivalents . One MET is the amount of oxygen consumed at rest . 31 METs can also be estimated from questionnaires such as the Duke Activity Status Index . 32,33 Like other aspects of functional status, functional capacity may influence access to food, housing, and financial resources, often through employment. Conversely, poor diet, unstable housing, poverty, and inability to access care and medications may influence functional capacity. These relationships are often exacerbated among chronically ill populations. 7 Despite evidence of a relationship between SDoH, cardiovascular disease, and other health outcomes, the relationship between SDoH and functional capacity has yet to be examined. Building on prior literature, we sought to characterize the relationship of SDoH, in particular food insecurity, housing instability, and financial hardship, with functional capacity, among highly vulnerable adult primary care patients with chronic medical and behavioral conditions. We hypothesized that the presence of 1 or more SDoH will be associated with reduced functional capacity. Further, we hypothesized that food insecurity, housing instability, and financial hardship will each be independently associated with reduced functional capacity. --- Methods Our primary analysis modeled functional capacity in relation to the presence of any 1 or more insecurities. Our secondary analysis characterized the independent effects of each insecurity on functional capacity. Finally, a tertiary analysis modeled functional capacity as a function of the total number of SDoH . --- Data and Setting We used baseline survey results from Integrating Behavioral Health and Primary Care, a multicenter randomized study of chronically ill primary care patients from 2016 to 2021, described in detail elsewhere. 34 Baseline data were collected before the COVID-19 pandemic. Data were collected from 4023 adults with multiple chronic conditions from 44 primary care practices across 13 states. To be eligible for this study, participants needed to have either at least 1 chronic medical and 1 behavioral health condition or greater than 2 chronic medical conditions. Participants also needed to be an active patient of a participating study practice as evidenced by at least 2 visits in a period of 24 months for any purpose, including at least 1 in the most recent 6 months. The presence or absence of each qualifying condition, and the dates of office visits, were determined by review of electronic health record visit data, problem lists, medication lists, and laboratory results. The primary outcome was functional capacity measured by the DASI, 32 a 12-item questionnaire that assesses the ability to do self-care, housework, sports, and other activities. The DASI generates an estimated maximal oxygen consumption, which correlates with results of treadmill testing [31][32][33] and long-term health outcomes in chronically ill patients. 29,35,36 We converted the DASI to METs , where higher METs indicate better functional capacity. SDoH was captured using 4 yes/no questions . The primary predictor variable was a binary indicator of the presence of any 1 or more of the 3 insecurities . Food insecurity and financial hardship were captured using 1 question while housing instability was captured using 2 questions. A count variable was created representing the number of SDoH insecurities present . Potential covariates associated with both SDoH and functional capacity were chosen based on clinical knowledge and prior literature. Person-level demographic covariates included age, sex , race , ethnicity , marital status , employment status , annual household income , and education . We also included medical and behavioral conditions as potential covariates in the model including arthritis, 37 Each participant's home address was mapped, and various neighborhood covariates were identified for potential inclusion in the final models. The Social Deprivation Index 38 is a census tractlevel composite measure of deprivation based on income, education, employment, housing, singleparent household, and access to transportation. Census tract urban/rural status was based on Rural Urban Commuting Areas, 39 which are derived from population density, urbanization, and daily commuting. Population density was assigned from their home census tract. Potential practice-level covariates included information on behavioral health services, specialty, volume of encounters, type , percent of patient population on Medicare, and county-level demographic measures . --- Statistical Analysis We used Wilcoxon rank-sum tests to compare the unadjusted distribution of functional capacity between those with and without 1 or more SDoH. Multilevel linear regression models were used to estimate the mean difference in functional capacity in METs by SDoH . Practice was included as a random intercept to account for correlation of patient-level measures within the primary care practice in which they were recruited. All predictors and covariates were included as fixed effects. The primary analysis modeled the effect of any 1 or more SDoH on functional capacity. Secondary analyses were independently performed for each of food, housing, and finance and the total number of insecurities. We repeated the main analysis while restricting the sample to those who met criteria for specific subgroups. For the sake of parsimony and model reduction, covariates were included in the final model only if they changed the coefficient of SDoH on functional capacity by more than 610% in a model containing only 2 predictors . All tests were 2-tailed and the threshold for statistical significance was a = 0.05. Stata 16.1 was used for data management and statistical analysis. The University of Vermont Institutional Review Board approved this study. --- Results Two thousand seven hundred sixty-three participants were available for analysis. One or more insecurities were reported by 28%. Financial hardship was the most prevalent , followed by food insecurity and housing instability . Most participants with an insecurity only had 1 , 8% had 2 insecurities, and 1% had 3 insecurities. Participants with any insecurity tended to be younger, black or other race, female, not married, not working, lower income, less educated, and living in socially deprived, densely populated areas compared with those without an insecurity. Most chronic diseases were more prevalent among participants with insecurities . Functional capacity ranged from 2.74 to 9.89 METs . The final sample had missing information on 249 of records, of which 229 were missing data on METs and 64 were missing information on some or all of the SDoH. In the final multivariable models, there was 12% to 13% missing data. The records with missing data that were excluded from the final models did not significantly differ from those with complete data in terms of age, sex, race, ethnicity, functional capacity, and SDoH. The unadjusted effect of any or more SDoH on functional capacity was À0.88 METs . Age, marital status, income, total count of chronic conditions, and census tract SDI all modified this coefficient by more than 10% and were included in the final model. In a multivariate analysis, the effect of any SDoH was À0.62 METs . The unadjusted effects of food, housing, and financial insecurities on functional capacity were À0.75 METs , À0.60 METs , and À0.84 METs , respectively. Age, marital status, income, education, and total count of medical and behavioral conditions all modified the coefficient by more than 10% and were included in all 3 models. In addition to these variables, mood disorder and census tract SDI were included in the final food insecurity mode; urban/rural status, population density, mood disorder, and arthritis were included in the housing instability model; and census tract SDI was included in the financial hardship model. In multivariable models, food, financial, and housing insecurities were associated with a reduction in functional capacity of À0.48 METs , À0.44 METs , and À0.59 METs , respectively . The number of insecurities had a dose-response relationship with functional capacity. In unadjusted models, each additional insecurity reduced functional capacity by À0.51 METs . Age, marital status, income, total count of chronic conditions, and census tract SDI all modified the coefficient by more than 10% and were included in the final model. In multivariable analysis, each additional insecurity resulted in a reduction in functional capacity of À0.38 METs . --- Discussion We used a cross section of patient-reported surveys collected from a multicenter randomized trial of adult primary care patients with multiple chronic conditions to investigate the relationship between SDoH and functional capacity. We found that the presence of 1 or more insecurities resulted in a loss of 0.62 METs or roughly 10% of total functional capacity. This is roughly equivalent to being able to walk briskly versus walking at a leisurely pace . We also found that food insecurity, housing instability, financial hardship, and the total number of insecurities were each independently associated with functional capacity. Our findings are consistent with literature showing that SDoH negatively affects health, especially for younger age groups, females, and those with lower education and more chronic illnesses. [5][6][7][8] Previous studies have shown food insecurity, housing instability, and financial hardship were related to functional disease and lung disease but not stroke. 7 Further, SDoH are associated with behavioral and biomedical risk factors for cardiovascular disease. 40 This study expands on these findings by confirming this association among primary care patients with multiple chronic conditions and investigating the specific functional outcome of functional capacity. Improving functional capacity has the potential to help improve physical activity and maintain independence and aging in place for older adults, reduce health care costs, and improve quality of life. Because we saw an association between SDoH and functional capacity in this population, we posit that improving SDoH could potentially improve functional capacity. Future longitudinal studies should address this question to confirm a causal link. The mechanism of the association between SDoH and functional capacity is complex. Food insecurity can reduce consumption and change the foods eaten. 41 Cheaper, energy-dense food tends to be higher in calories, sugars, and fats 42,43 and may contribute to the development of chronic diseases such as diabetes and hypertension, 12,13 which can lead to reduction in functional capacity. Food insecurity is associated with decreased physical activity, potentially related to conserving energy. 44 Housing instability and financial hardship can reduce access to care and medications, leading to chronic diseases and poor functional capacity. Another commonly proposed mechanism is that SDoH increases stress, resulting in high cortisol levels that can lead to heart disease and poor functional capacity. 45 The prevalence of food insecurity in our sample was similar to national estimates, but housing instability was higher than estimates of homelessness and financial hardship was higher than national estimates of poverty. These findings could be unique to our sample of chronically ill adults or due to the various ways housing and financial insecurity are measured and defined. Food insecurity is ubiquitously defined as "limited or uncertain availability of safe and nutritionally adequate food." 46 In our sample, the prevalence of food insecurity was 11% compared with an estimated 12% in the general US population. 2 There are, however, no standard definitions for housing instability or financial insecurity. Housing instability has variously been defined as frequent moves, difficulty paying rent, spending more than 50% of income on rent, overcrowding, and number of evictions. 47,48 In our survey, housing instability is comparable to homelessness and significantly higher than national averages , perhaps due to the population being chronically ill and older. Similarly, financial hardship has been defined directly in terms of consumption or indirectly in terms of income. The prevalence of financial hardship was 24% in our sample compared with national poverty estimates . Our financial hardship question focused on difficulties in paying for life necessities, which may occur more frequently than poverty based on income. Alternatively, our population may suffer more financial hardship than the general population due to chronic illnesses. Previous studies have shown that individuals with food insecurity, housing instability, and financial hardship are more likely to have access to care problems. 7,47 However, our population is unique in that participants have evidence of access to care, suggesting different mechanisms are in play. Perhaps this chronically ill population prioritizes access to care over other necessities such as food or housing. Access to care alone may not be enough to combat SDoH challenges and related sequelae. Race and structural racism are well documented to be associated with SDoH and health inequities. [49][50][51] Our findings indicate that not only is SDoH associated with function but the effects of SDoH on functional capacity exist above and beyond those mediated through race. In other words, SDoH and race seem not to be proxies for each other. To improve patient functional status and quality of life, it may be important to address SDoH and racism jointly. This study has important limitations. Although the data were collected from patients with chronic conditions from diverse parts of the country, the results may not be generalizable to other populations and settings, such as those without access to care. Second, because this is a secondary analysis, it used a limited definition of SDoH. We did not have information on transportation challenges, violence, the built environment, or social justice challenges. However, we did obtain robust data on the 3 SDoH that were measured. Third, much of the data, notably the estimates of functional capacity, were self-reported. However, the DASI has been validated multiple times, including in chronically ill patients. 29,35,36 Fourth, the cross-sectional nature of the study limits causal inference. For instance, although these data support the hypothesis that SDoH impacts functional capacity, they are also consistent with the reverse . Although we controlled for several potential confounding influences, we cannot eliminate the possibility of an unmeasured confounder. For instance, we did not have data on health insurance. However, all participants received care, indicating good access. Finally, data were missing from 13% of records in the final models. Fortunately, these records did not significantly differ by SDoH, functional capacity, or demographics from those that were included. Primary care offers a promising, if underused, opportunity to intervene in SDoH. Although primary care physicians understand that social factors influence health, many avoid asking about them, 52 and many primary care practices have not invested in developing platforms to address SDoH. 53 Nonetheless, strategies to address SDoH in primary care are emerging. 54,55 There is a need for future studies to explore the role of screening and intervention by primary care providers to mitigate or prevent SDoH. This is the first analysis of SDoH and functional capacity. It shows that the presence of 1 or more SDoH is associated with lower functional capacity in primary care patients with multiple chronic conditions and suggests primary care as a fruitful setting for intervening. To see this article online, please go to: http://jabfm.org/content/ 34/4/688.full.

Social determinants of health (SDoH) including insecure access to food, housing, and financial resources are critical threats to overall health. We sought to examine this relationship among adult primary care patients with multiple chronic conditions. Methods: We obtained cross-sectional data on 2763 adults with chronic medical and behavioral conditions or greater than 2 chronic medical conditions from a survey of participants in Integrating Behavioral Health and Primary Care, a multicenter randomized trial. Results: The prevalence of 1 or more insecurities was reported in 29% of participants, including food (13%), housing (3%), or financial (25%). Functional capacity ranged from 2.74 to 9.89 metabolic equivalents (METs) (median, 6.05). The distribution of functional capacity was significantly lower for those with any 1 or more SDoH than for those without. Each insecurity independently affected the functional capacity in multivariable analysis. Conclusions: Among primary care patients with chronic conditions, SDoH are associated with poorer functional capacity, independent of other social and demographic factors. Primary care offers a promising, if underused, opportunity to intervene in SDoH. There is a need for future studies to explore the role of screening and intervention by primary care providers to mitigate or prevent SDoH.

Introduction The scientific inquiry into human happiness, in the form of a modern empirical field of study, has become an integrated line of research throughout various disciplines. Concepts such as "subjective well-being", "happiness", "positive affect" and "life satisfaction" are nowadays employed in various areas; from sociology, economics and psychology, to gerontology, psychiatry and medicine. There is even a specialized field called positive psychology that focuses on strategies for enabling the good life for the individual . In the year 2000, the Journal of Happiness Studies was founded, and in 2006 the Journal of Positive Psychology. However, these thematic and multidisciplinary journals are of a recent date. There exists an interesting earlier historical account of happiness studies that we wish to shed light on from a scientometric point of view. In this article, we aim at drawing a more precise map of the scientific research contexts in which happiness studies has become a core activity, an integrated part of research, or a peripheral side-activity to normal science within a pre-existing discipline. We will use scientometric methods to explore the places where happiness research has emerged, and furthermore, in which disciplines the core concepts have been put to use for scientific research. Consequently, the aim is to show how a new research field -"happiness studies" -has emerged, consolidated and become integrated into practices of research. But, a purely quantitative account is insufficient for identifying the relevant aspects of the content of specific research practices. We will thus, along the lines of Van Heur, Leydesdorff and Wyatt combine quantitative and qualitative methods. This way, we are able to understand not only the frequency of well-cited authors, articles and journals, but also why these units acquire specific importance, what the historical contexts are, and why some attempts to conduct happiness studies disappear from history as research develops and changes. The impact of happiness studies has grown in relevance during the past two decades. Today, various measurements of happiness are frequently used in cross-national comparisons outside academic research, for example the United Nations Human Development Report , and the World Happiness Report . Happiness and well-being are becoming increasingly important issues in policy-making, which could be regarded as a return of the "greatest happiness principle", as outlined by Jeremy Bentham and John Stuart Mill in the 19th century . In the UK, the Office for National Statistics even provide regular nation-wide measurements of various aspects of well-being and happiness, as a compliment to GDP . Recently, a trend of "positive psychology" has become increasingly popularized for a wider readership , where the development of concrete strategies for the individual to increase her levels of happiness in life are made the focus of inquiry. The wide dissemination of happiness studies is, nevertheless, quite a new phenomenon. It seems that there is even a reason for speaking about a "happiness turn" taking place at the turn of the millennium, influencing both the direction of science and politics, and being reported on widely in the mass media and popular culture . To find the origins of such a "turn", however, we must go back several decades in time, in order to find its scientific place of birth. Only then is it possible to test the "happiness turn hypothesis" against empirical publication data. --- Methodology To create a broad dataset1 that includes multiple disciplinary research fields, Web of Science topic searches were based on four search terms: "happiness", "subjective well-being", "life satisfaction" and "positive affect". The selection of search terms were the result of a systematic literature review where core concepts were identified. Our goal was to create a dataset that would encompass a wide variety of studies concerned with human happiness and well-being, yet distinct enough to exclude the much broader field of research which aims at improving "quality of life" in general. In the literature review, we analyzed how the terminology of happiness studies has changed qualitatively over time by consulting a number of authoritative and well-cited literature reviews written by happiness researchers . This review showed that in the first half of the 20th century, the term "happiness" was commonly used as a distinctive term. Analyzing Wilson's Correlates of Avowed Happiness displays how term "happiness" had acquired a social-psychological definition during the first half of the 20 th century, a distinction that is of interest to us because it marks a departure point for empirical research on happiness, in contrast to a purely philosophical account, which preceded the first social scientific surveys. Then, especially in the field of gerontology, the term "life satisfaction" started to gain momentum in the 1960s, as highlighted by Neugarten et al.'s Life Satisfaction Index, a Scale of Measurement, and it became a widely used concept, even up until today. Moreover, in the same period, Bradburn's The Structure of Psychological Well-being introduced the concept of "positive affect" as a way of understanding and measuring human happiness. Finally, the term "subjective well-being" picked up speed two decades later with Diener's article Subjective Well-being, which is one of the most cited articles in our dataset. This article marks the beginning of a conceptual consolidation, evidenced not only by Diener's 1984 article, but also of the article Subjective Well-being: Three decades of Progress , and, as a recent example, by Lyubomirsky et al. , where 225 articles were included in a large meta-analysis. Analyzing these literature reviews, we have been able to identify four inclusive search terms, which are not limited to specific clinical or specialized uses, while simultaneously avoiding the very broad terms of "quality of life" and "wellbeing", terms that stretch beyond the scope of a distinct happiness studies field. These four terms overlap to some degree, but as the co-occurrence matrix shows, they are not used synonymously. Thus, it is possible to conduct happiness research using only one or two of these terms. We chose not to include terms that were wider in meaning, for example the single terms "affect" or "well-being" without their distinguishing prefixes "positive" and "subjective", respectively. Not only would we then include a lot of research unrelated to happiness studies, we would also collect far too much data for in-depth analysis . In conclusion, we have thus created a dataset based on both qualitative and quantitative choices. We have tried to balance between two trade-offs: On the one hand, there is a chance we miss out on highly specialized concepts that are qualitatively important for defining happiness studies by limiting our study to only four search terms. We also run the risk of excluding the types of research that employ very general terms when conducting happiness studies, such as "quality of life", "affect" or "well-being". However, our qualitative review of the field strongly suggests that the four terms selected are at the core of the canonical literature, and our quantitative analysis shows that these articles belong to the most cited backbone of publications . Additionally, the use of cited references allow us to identify highly cited publications even if they are not found in our retrieved dataset. --- Clustering technique We base our study on cited references and the clusters that emerge when these are quantified using the VOSviewer software package . Following Small we treat cited references as being symbolic, in the sense that they are representing "experimental findings, methodologies, types of data, metaphysical notions, theoretical statements or equations -or, in general when dealing with citations, any statement which may be taken as characterizing or describing the cited document." . In other words, when an author cites an article, he or she creates its meaning -this is the symbolic dimension of the citation. But the very act of citing is also performative: statements and scientific findings acquire and change their meaning when they are in the "hands of later users" . In our study we approach this phenomenon from an aggregated point of view, using bibliographic coupling of sources as a technique to cluster journals in which papers that cite similar literature are found close to each other. The clusters we describe are based on cited references that are mapped onto a landscape of journals that is simultaneously created, which we in turn interpret as deriving their consistency from a symbolic dimension, where authors have cited specific articles as a process of incorporating findings, methodologies and theoretical notions that belong to a specific concept or idea . An alternative approach would be to use a pre-defined map, such as presented by Rafols et al. While we agree that the global map of scientific publications is needed for positioning a field in a "total" scientific landscape, our local map has another purpose. We are interested in any scientific activity that has any connection to happiness studies whatsoever. This is how happiness studies is "constructed" as a dynamic area of research involving heterogeneous scientific actors. Thus, when we discover a consistent cluster in our material, it means that we are describing a concept or idea unfolding in the field of happiness studies; and from a historical point of view, we try to detect these clusters as they emerge over time. --- Results To understand the trends in happiness studies, a historical account is needed, and first and foremost it is necessary to look at the total expansion of the field, compared to the Web of Science average . As shown in Figure 1, "happiness studies" is a relatively young field of study, in terms of publication frequency. From 1990, there was an increase in publications, which accelerated during the first years of the 2000s when all four search terms began to increase drastically. Compared to the almost linear growth of the entire Web of Science during this time, happiness studies began to make a quantitative leap only at the turn of the millennium. include more than one of the terms, the sum can be higher than 100 percent. Moreover, prior to the 1990s, as shown in Figure 1, the total number of published articles is very low, hence the straggly patterns in the left side part of the graph. Moreover, Figure 2 indicates that the four search terms stabilized already in the beginning of the 1990s, as the first increase in publication frequency started. Before this stabilization, "happiness" and "life satisfaction" dominated the area of study, but during the 1990s, an increasing number of publications containing the more technical terms "positive affect" and "subjective well-being" became popular. Today, there is still a quantitative difference in usage among the terms, however much smaller. This also indicates that happiness studies has gained a high enough frequency in publications for us to speak of a field of scientific research that produces meaningful patterns and regularities as objects of analysis. --- The emergence of "happiness studies" in scientific journals To understand the various contexts of research that have been involved in the making of happiness studies, we visualized the bibliographic coupling of sources cited in the data set. The four search terms yielded sporadic search hits dating back to 1904, but the hits before 1960 are too few to produce meaningful quantitative results 2 . We divided the material in two 15-year intervals for the period 1960-1989. From 1990-2013 we employed 5-year intervals, although the last set only comprises the broken interval of 4 years 2010-2013. This irregular division is motivated both by the increase in publications, as described in Figure 1 and 2, and because a higher degree of resolution is needed to spot the emergence of new fields of study that adopted happiness measurements from the 90s and onwards. In the presentation of these results, there is a methodological "lag" of two kinds. Firstly, citations are delayed due to the slow process of publication ) and a higher citation rate of older literature . Secondly, new journals are delayed for inclusion to the WoS because of the index inclusion criteria 3 . Thus, our results must be interpreted with such "lag effects" in mind. --- 1960-1974: The gerontological emergence So where did happiness studies come from, as a scientific enterprise? Finding the origin of a multidisciplinary research field, such as happiness studies, is of course difficult using only quantitative data. However, when analyzing the publications between 1960 and 1974, a pattern emerges. The There is also a small cluster around Psychological Reports that consists of articles treating various problems, from sexual behavior and happiness, to geriatric and marital correlations with happiness levels. 2 For the period 1904-1959, see additional online material at http://scientometrics.flov.gu.se/happiness/scientometrics/ Two publications4 are of special relevance in this gerontological departure phase. The article "The Measurement of Life Satisfaction" by Neugarten et al. introduces the "Life Satisfaction Index", an important scale for measuring satisfaction with life. This article will be cited frequently in the future, throughout all our data, but especially within gerontological publications. Moreover, Bradburn's book The Structure of Psychological Well-Being , is a constitutive publication for the emerging field of happiness studies, as it introduces another scale of measurement: the "Affect Balance Scale", which measures positive and negative affect. Thus, according to our findings, the first iteration of "happiness studies" takes place primarily in connection with gerontological research on "successful aging". To understand the research problems that this line of research was occupied with, and how these problems were promoted by factors external to science, can only be revealed properly by further qualitative in-depth analyses. The scientometric analyses, however, provide a picture of both the type of journals and the central publications of this formative period. Moreover, during this first 15-year period, the scarcity of publications on the topics studied here, needs to be taken into account when assessing the validity of quantitative measures. --- 1975-1989: Consolidation of Gerontology. Emergence of Social Indicators and Social Psychology The first gerontological phase consolidates during the next period of analysis. Gerontological research and family/marriage studies start to share similar references, as shown by their cluster proximity. This could be interpreted as gerontology and family studies are sharing conceptual structures that produce this citational proximity when happiness is the object of study. In other words, when these researchers want to study happiness, they retrieve similar concepts, which in turn are integrated in their research. In Figure 3 it is also possible to spot the emergence of a cluster of articles published in Social Indicators Research. When going into details for this particular journal, it is worth noting that 29 out of a total of 41 articles between 1978 and 1989 cite Andrews and Withey's book Social Indicators of Well-being 5 . During the same period, only 4 articles were published that did not cite any of Andrews' publications. Social Indicators of Well-being, as a central publication, and Andrews and Withey6 as influential researchers, can be seen in this case as an "obligatory passage point" for publishing articles that set out to measure well-being in the late 70s and 80s. Andrews and Withey not only inspired researchers to think of well-being as a distinctively social indicator, they also introduced a way of measuring it, called the "Delighted-Terrible Scale" . Consequently, there is more than one reason for the centrality of this work; the general approach of using happiness as an indicator, and the methodological use of a specific scale of measurement. Interestingly, the emergence of Social Indicators Research is only weakly correlated with the developments in gerontology. Only in rare cases do they share cited references in this emerging phase, at least when looking only at the publications in the core journals: Journals of Gerontology, Gerontologist and Social Indicators Research. They do, however, meet in broad literature reviews such as Diener , and in some cases when, for example, the Life Satisfaction Index of Neugarten et al. Starting in 1990, we see a sudden growth in our dataset . As a consequence, the fields of gerontology, social indicators, marriage and family, and personality psychology crystallize as competing centers of gravity . The complete domination of gerontological and geriatric publications is from now on broken, especially by the emergence of Social Indicators Research, which could be seen already in Figure 3 in the previous decade. There are also new clusters arriving from all sides. Our search terms appear also in publications from medical and clinical sciences. Here we find journals such as Medical Care, where publications concerning life satisfaction and happiness in relation to chronic disease, injuries and surgery are published. However, we also find, on the opposite side, the Journal of Consumer Research, in which articles that measure shopping experiences and consumer product choices in relation to happiness begin to appear. We may conclude that in the 1990s the central clusters are accompanied by a diverse range of specialized journals that measure happiness in different ways, for very different reasons. : 1990-1994, upper right: 1995-1999, lower left: 2000-2004, lower right: 2005-2009. Minimum number of documents of a source has been kept to two7 . On the author level, there is a clear trend throughout the 1990s. Two teams of researchers create three publications that overshadow much of the landscape, in terms of cited references ( --- 2000-2009: The Diener-Watson dominance and the emergence of the Journal of Happiness Studies During the first five years, after the turn of the millennium, there is a consolidation of references to Hedonic and Eudaimonic Well-Being" . The reason for these new articles to appear on the list of most cited articles is that they propose a different way of thinking happiness, following Aristotle's notion of "eudaimonic happiness" . Here, an alternative conceptualization and operationalization of human happiness is presented, one that takes personal autonomy, self-acceptance and positive relations with others into account. Thus, from around 2005 and up until today, there are competing ways of thinking human happiness among the most cited articles. On the one hand, the satisfaction with life scales and the positive/negative affect measures depart in what may be called "hedonic" concept of happiness, where the experience of what makes life pleasant and unpleasant are at the center of investigation. On the other hand, researchers working with "eudaimonic happiness" instead tend to shift away from the completely subjective aspect, instead focusing on the realization of one's true potential and living a life in accordance with one's "true self". Happiness studies is, one could say, a divided field in terms of core concepts8 . --- Contemporary Happiness Studies So, what is happiness studies today? First of all, it is a field that grows very rapidly. 36 % of the articles that we extracted from the Web of Science since 1904 were published as late as between 2010 and 2013. There is a clear indication that this diverse field is indeed very productive. Today, it covers a broad spectrum of scientific disciplines and areas of study, which can be seen clearly when reading Figure 5 from right to left. First, we encounter what could be labeled as biological, neurological, clinical and psychiatric journal titles. These studies are often specialized and focus on a specific group of patients and/or disorders, where happiness measures are integrated into clinical evaluations and assessments of the efficacy of a particular therapy. Next, we find psychological journals that border with social psychology, personality studies and gerontology. This section comprises a large body of the citing references, and may be thought of as one of the mainstreams of happiness studies. In the very center of the figure, we find the As revealed already in Figure 1, this 3-year period marks a steady growth in absolute numbers of publications, a continuation of a trend beginning at the turn of the millennium. But, as seen in Figure 5, it also entails a horizontal growth. Happiness studies has diversified, in terms of journals. Measurements of happiness have been included in articles published in such diverse areas as library science, economics, vocational science, gerontology, all forms of psychology, genetics, neuroscience and physical medicine. On a qualitative level, the various studies found in these disciplines all have quite different connections to happiness studies. Some of them would not even say they are conducting research in this area, especially in the medical sciences, where subjective well-being and life satisfaction often are closely related to specific treatments or therapies. --- Conclusion -A "happiness turn"? Depending on where you are situated in the social-, behavioral-or medical sciences, the field of "happiness studies" may look very different. The use of scientometric data in general, and cited references in particular, is a productive way of attempting to define and study this emerging field of research. We have found that happiness research took off in the fields of gerontology and social indicators research. These were the fields of study where measurements of life satisfaction and positive/negative affect were conducted to tackle the problem of "successful aging" and how to find relevant indicators of perceived life quality. During the late 1970s and the 1980s, the difference between the gerontological studies and the social indicators movement became more defined. Even though both camps explored life satisfaction and well-being, they drew on slightly different bodies of literature as their main references. Also, during the mid-1980s, a handful of important articles concerning scales and methods of measurement were published. These articles would have large impact later on, during the 1990s. In the 1990s, wider psychological and social psychological research started to emerge, in which happiness measures were integrated. Also, during this prolific century, clinical and medical studies began to use measures of happiness, thus widening the field considerably. The key development in the decade before the turn of the millennium was the widespread acceptance of two standard scales for measuring subjective well-being: Diener et al.'s Satisfaction with Life Scale and Watson et al.'s Positive and Negative Affect Schedule. These two publications began to dominate the field of happiness studies, and continue to do so even today. Consequently, the field strove towards a kind of conceptual unity, where particular common procedures contributed also to a steady expansion of the field. With the turn of the millennium, and the decade that followed, economists started to conduct research on the effects of the economy on happiness . Even though the relationship between income and happiness had been explored earlier , it is during this time that a citational pattern emerges in the scientific literature. Moreover, this phase also gave birth to positive psychology and specialized journals, such as the Journal of Happiness Studies and Journal of Positive Psychology. Yet, as proposed in the introduction of this article, is it really reasonable to speak of a "happiness turn" taking place at the turn of the millennium? Many of the influential authors in the field claim that to be the case. For example, Layard writes that a "new psychology now gives us real insight into the nature of happiness and what brings it about" . And Emmons claims that, "[t]he field of positive psychology, initiated by Martin Seligman in the late 1990s, has begun to mature as a scientific discipline" . This latter quote not only reconstructs the scientific advances to have taken place further back in time, it also is a case of where a reference functions as a rhetorical "device", as discussed in Gilbert . Even a notable critic of happiness research claim that there has been a significant happiness turn in this period of time . Our data suggests that there has indeed been a significant increase in happiness studies publications over the last decade, a trend that peaked in the period 2010-13, and seems to continue to expand in contemporary research. The notion of a "happiness turn", however, implies that there was another trend or focal point before the turn. Some of the leading authors in the field write in such a key, arguing that the center of attention has shifted away from purely economic measurements towards subjective forms well-being and happiness . Evaluating such a claim requires a different methodology than ours. What we are able to show is perhaps not so much a turn, as it is a study in a rapid diffusion and growth of happiness studies, which appears in heterogeneous and scattered areas of study. Thus, we suggest that there is not one singular turn to happiness. Rather, measurements of happiness and well-being may be interpreted as what Bruno Latour calls immutable mobiles . In other words, the methodologies and standardized practices of measuring happiness and well-being have been made plastic enough to travel between scientific disciplines, reaching further and further into specialized areas of study, without losing their identity. This way, we may say that happiness studies has a "coverage" across disciplines, without implying that it necessarily is part of the core research activity. Happiness studies may, on the one hand, be the very object of study in itself. This is the case when reading articles in for example Journal of Happiness Studies. However, and equally important for our attempt at studying the emergence the field, there is on the other hand plenty of research in which measurements of well-being and happiness are instead auxiliary components of a larger research question. Perhaps is it then not so much an "happiness turn" that we have rendered visible, but rather the emergence of a focal point for research, as many different disciplines have turned towards happiness, especially during the past two decades. Such a turning towards happiness cannot be solely understood from an internalist perspective on science. The accelerating interest in happiness measurements must rather be thought of as deeply intertwined with the common production of science and society. --- Appendix

This article analyzes "happiness studies" as an emerging field of inquiry throughout various scientific disciplines and research areas. Utilizing four operationalized search terms in the Web of Science; "happiness", "subjective well-being", "life satisfaction" and "positive affect", a dataset was created for empirical citation analysis. Combined with qualitative interpretations of the publications, our results show how happiness studies has developed over time, in what journals the citing papers have been published, and which authors and researchers are the most productive within this set. We also trace various trends in happiness studies, such as the social indicators movement, the introduction of positive psychology and various medical and clinical applications of happiness studies. We conclude that "happiness studies" has emerged in many different disciplinary contexts and progressively been integrated and standardized. Moreover, beginning at the turn of the millennium, happiness studies has even begun to shape an autonomous field of inquiry, in which happiness becomes a key research problem for itself. Thus, rather than speaking of a distinct "happiness turn", our study shows that there have been many heterogeneous turns to happiness, departing in a number of different disciplines.

Introduction The high rates of adolescent obesity in the United States remain a significant public health concern. Nearly 1 in 4 adolescents aged 12-19 years in the United States had obesity from 2017 to 2020 [1]. Youths of color experience disproportionately higher rates of obesity, with 26.2% of Hispanic and 24.8% of non-Hispanic Black youths ages 2-19 years with obesity, compared to 16.6% of their non-Hispanic White peers [1]. Given the adverse effects associated with adolescent obesity, including elevated risk for diabetes, heart disease, and shorter life expectancies, developing intervention strategies with a health equity lens to prevent and treat obesity, particularly among youths of color who face disproportionately higher rates, is critical [2][3][4]. Digital or mobile health interventions, defined as health services delivered electronically through formal or informal care, hold promise as a modality to engage adolescents in improving obesity-related health behaviors, such as diet and physical activity [5][6][7][8]. Studies to date that have evaluated digital health interventions as a primary or supplemental tool within behavior change obesity interventions have primarily targeted adults or have assessed programs that jointly engage adolescents and their parents or guardians [6,9,10]. Prior digital health interventions targeting adolescents have largely focused on chronic disease management rather than health behavior change related to obesity prevention and treatment [7,11]. Further, research on digital health interventions targeting obesity-related behaviors with content and strategies tailored for adolescents of color is limited. Given the high prevalence of smartphone and social media use among adolescents, social media-delivered health interventions are a promising approach to engage adolescents in healthy weight management [12]. In 2021, 84% of adolescents 13-18 years of age reported ever using social media [13]. Social media use among this age group increased during the COVID-19 pandemic, with an average of 1 hour and 27 minutes per day spent on social media in 2021, up from 1 hour and 10 minutes in 2019 [13]. A 2018 Pew Research study found that 95% of 13-to 17-year-olds reported having access to a smartphone and nearly half reported being on the internet almost constantly, with over 70% of Black and Latine youth participants reported using at least 1 social media platform [14]. The Pew study also reported gender differences in social media platform preference among adolescents, with females more likely to prefer Snapchat than males and males more likely to prefer YouTube than females. The prevalent use of social media platforms among all adolescents, including those of color, highlights the potential of social media as a vehicle to deliver accurate and engaging health content to promote healthy weight management behaviors. The limited literature on adolescents' exposure to and consumption of health information, particularly related to healthy weight management, through social media platforms has produced mixed findings. A small pilot study evaluating the consumption of health-and fitness-related social media content among adolescent females found that participants did not follow health-related pages or accounts and did not actively search for health content on social media [15]. A systematic review of social media interventions with content targeting nutrition and obesity among adolescents and young adults found that two-thirds of such interventions were associated with at least 1 clinical nutritional or dietary behavioral improvement [16]. However, none to our knowledge have specifically examined the efficacy of such interventions among adolescents of color. This mixed methods study aims to examine social media habits, preferences, and obesity-related behaviors among adolescents of color and understand intervention preferences to inform the development of future healthy weight management behavioral intervention delivered via social media through cross-sectional surveys and focus groups among a sample of adolescents of color. --- Methods --- Design This study collected quantitative and qualitative data from high school students aged 14-18 years who identified as people of color in order to assess adolescents' weight management behaviors, attitudes, practices, and social media preferences. Participants were asked to answer questions related to their social media habits, preferences for physical activity and nutrition intervention content and delivery, preferred social media platform, self-reported measures of obesity-related behaviors , and height and weight via an anonymous cross-sectional web-based survey and web-based focus groups. --- Ethics Approval Study procedures were approved by the Institutional Review Board of Boston University Medical Campus . --- Recruitment, Setting, and Procedures The investigative team contacted youth-based or youth-affiliated organizations in their network, including the Massachusetts Alliance of Boys & Girls Clubs , high schools in California, and community partners in Massachusetts and California to recruit participants. BGC staff, high school administrators, and community partners in Massachusetts and California were informed of the purpose and methods of the study. In total, 3 BGCs in Massachusetts and 2 high schools in southern California indicated interest in participating and were asked to share physical recruitment flyers with adolescents of color ages 14-18 years. Adolescent participants were also invited to share the survey with their social networks. Survey recruitment and administration took place from March 2021 to April 2022 with interested and eligible participants provided with a web-based QR code to access and complete the 1-time web-based survey. Focus group recruitment and facilitation took place from April 2021 to September 2021. Study staff contacted interested and eligible focus group participants to identify a date and time for a web-based 1-hour meeting . Focus groups were conducted by a trained facilitator using Zoom, lasted 45-60 minutes in duration, and were recorded and transcribed. --- --- Measures --- Survey Measures Web-based survey questions measured self-reported sociodemographics, health behaviors, height and weight, and social media habits and preferences. Sociodemographics included gender ; age ; grade level; Hispanic or Latine ethnicity; race with more than one response permitted; and state or territory of residence in the United States. Items from the 2019 Youth Risk Behavior Surveillance Survey were used to assess health behaviors, including number of servings of fruit, vegetables, and sugar-sweetened beverages on a typical day in the past week [17]; number of days engaged in at least 60 minutes of physical activity per day over the past week; number of hours slept on an average school day and a weekend day over the past week; and number of hours engaged in screen time on an average school day. Survey items on social media habits and preferences assessed current use of major platforms as well as asked participant to identify their single most-used platform. Participants reported usage frequency for each platform of interest and were asked to identify their preferred platform to receive health information and connect with other adolescents of color on health behaviors. --- Focus Group Measures A trained facilitator asked a series of open-ended questions assessing social media usage and preferences, health-related concerns, and design and content preferences for a social media intervention to address obesity risk behaviors . --- Data Analysis --- Quantitative Survey Data Analysis Descriptive statistics were compiled to characterize the study population according to sociodemographics, health behaviors, social media usage, and age-and gender-adjusted BMI-based weight status categories. Race and Hispanic or Latine ethnicity were combined into mutually exclusive race and ethnicity categories: Hispanic or Latine; non-Hispanic Black; non-Hispanic Asian; or non-Hispanic other or multiple races. BMI was computed from self-reported height and weight and classified based on age-and gender-specific percentiles as follows: underweight , healthy weight , overweight , and obese , with missing or implausible responses excluded. Average daily screen time combined the number of hours watching television and using video games and computers. For participants who did not respond to the question on single most-used social media platform , a most-used platform was imputed based on their reported usage frequency of each platform, resulting in 93 responses for this measure. Overall social media usage frequency combined the reported frequency of use for each individual platform and was defined as frequent usage if the frequency exceeded once per day. Differences in health behaviors, social media habits, and covariates of interest by gender and weight status were explored using chi-square tests. Data presented in the tables were not stratified by gender or weight status as the study was not powered to detect differences by these characteristics, and data were not compared by race or ethnicity, state of residence, or social media usage frequency because the sample lacked sufficient distribution across subgroups. All analyses were conducted using SAS . --- Focus Group Data Analysis Focus group audio was transcribed verbatim and thematically analyzed by study staff. The analysis used a directed content analysis approach, where common themes were identified by a study staff member and used to formulate an initial codebook [18]. Two independent coders reviewed the transcripts and codes and revised the codebook to incorporate additional themes as needed. Initial interrater agreement of coding was 85.7%; discrepancies were resolved via discussion until 100% consensus was reached. The 2 coders also identified quotes that represented themes from focus group discussions. --- Results --- Survey Results A total of 101 adolescents of color completed the survey. An equal proportion identified as male and female, and 3.0% identified as nonbinary. The majority of respondents indicated Hispanic or Latine XSL • FO RenderX ethnicity and California residence . Over half of the participants had BMI in the healthy weight category, followed by overweight and obese . Social media usage frequency exceeded once per day for 88.1% of survey participants . The top most-used social media platforms included TikTok , Instagram , Snapchat , and Twitter . The majority of survey participants reported some use of TikTok and Instagram . TikTok was also the most frequent response for preferred platform to receive health advice and connect with others . Compared to males, female adolescents were less likely to engage in 60 minutes or more of moderate to vigorous physical activity daily and consumed more daily servings of SSBs . No other significant differences were found between male and female participants in terms of age, social media usage frequency, screen time, BMI, fruit and vegetable intake, or sleep measures. Participants with overweight or obesity were significantly more likely than those with healthy weight or underweight to report consuming more than one daily serving of SSBs . No other significant differences in health behaviors by weight status were observed. We were unable to assess whether weight status or health behaviors varied by frequent social media usage due to an insufficient number of respondents reporting usage frequency of once per day or less . Among the 93 participants with data on a single most-used platform , a significant difference was found in the distribution of most-used social media platform by gender . Among males, TikTok was the most-used platform for 40.0% of respondents, followed by Instagram and Twitter . Only 4.4% of males reported Snapchat as their most-used platform. Female respondents also reported TikTok as their most-used platform , followed by Snapchat and Instagram , with only 2.2% of females reporting Twitter as their most-used platform. The distributions of the most-used social media platform, preferred platform to receive health advice, and preferred platform to connect with others did not vary significantly by weight status . --- Focus Group Results --- Overview A total of 20 adolescents of color ages 14-18 years from 8 youth-based settings participated in 1 of 3 web-based focus groups for the qualitative portion of this study. Using a directed content analysis approach, 4 themes were identified and coded based on the focus group guide: preferred social media platform, purpose of platform use, satisfaction and engagement with platform, and preferences for healthy weight management content and delivery. These themes are summarized in Table 3 and presented alongside illustrative quotes. --- Preferred Social Media Platform TikTok emerged among focus group participants as the overall preferred platform of choice generally and with respect to health content. Most participants preferred TikTok due to its versatility, tailored content for the individual user, and options for multiuse engagement . The majority of participants also described initiating use or engaging in more frequent use of TikTok as a result of being isolated from their peers during the first year of the COVID-19 pandemic. Instagram emerged as the second most preferred platform with ease of being able to visually share information and updates, follow and engage with people outside of one's personal network , and connect with real-life network members . --- Platform Preference by Purpose or Function Participants discussed using multiple social media platforms for different purposes. With respect to obtaining new content or information and entertainment, TikTok emerged as the preferred platform. With respect to frequent messaging and engaging in conversation with others, including interfacing with new individuals or accounts, Snapchat and Instagram were identified as the preferred platforms. In terms of maintaining real-life connections with family members and friends, participants identified using Snapchat, Instagram, and Facebook. --- Satisfaction and Engagement With Platforms The majority of focus group participants discussed TikTok as yielding the highest amount of satisfaction and engagement. Participants reported that often learning or being exposed to something uplifting, positive, or humorous on TikTok and that this platform offered a variety of content that was constantly tailored to user preferences. Participants also valued TikTok as a platform for its novelty and relatability . The second most preferred platform was Instagram, where participants enjoyed viewing updates, viewing inspirational content, and seeing representation of other peers. --- Preferences for Weight Management Content and Delivery Key suggestions and preferences for healthy weight management content and delivery via social media that participants voiced included content that addressed the intersection of mental and physical health ; peer messengers and information from trusted sources ; posts or content that were relatable ; and consistency and frequency in posting content on small, attainable behavioral goals . Participants' views on the ideal source for health-related content were mixed; some participants wanted --- Discussion --- Principal Findings This mixed methods study is the first to our knowledge to examine social media platform use, design, and content preferences for social media-delivered weight management interventions among adolescents of color. Participants in our study reported most frequently using TikTok, followed by Instagram, Snapchat, and Twitter, and preference for platform varied by purpose of use. Participants reporting using TikTok primarily for entertainment, consumption, and creation of content, Snapchat and Instagram for frequent communication or messaging, and a variety of platforms to stay connected with family, friends, and peers. These findings are similar to a small pilot study conducted among adolescent girls aged 12-18 years who reported using Snapchat and Instagram as ways to communicate and stay connected with friends [15]. In concordance with recent trends on social media use among US teens ages 13-17 years from a 2022 Pew Research Center report, TikTok was the most popular social media platform reported by our sample of adolescents of color aged 14-18 years, followed closely by Instagram and Snapchat [14]. These patterns were reflected in both the study's survey and focus group data. Findings from our study are also in line with 2022 Pew data indicating higher shares of Black and Hispanic teens reporting usage of TikTok, Instagram, and Twitter compared with White teens. Focus group data from our study also support prior research findings that while adolescents are often exposed to health information via social media, they more frequently turn to websites versus social media when proactively searching for health information and are aware of the need to evaluate the accuracy and trustworthiness of health information obtained on the internet [19][20][21]. Importantly, our study added to the literature by examining adolescents' preferred platform by function in the context of a healthy weight management intervention and solicited open-ended input from adolescents of color on their preferences for health intervention content, design, and delivery. Quantitative and qualitative data from this study highlighted TikTok as one of the top preferred platforms of choice for learning new information on healthy weight management, and TikTok and Instagram as preferred platforms for connecting with others on healthy weight management behavioral changes. This study additionally identified adolescents' specific healthy weight intervention design preferences, such as trusted sources for health information , consistency and high frequency of content exposure, importance of being able to relate to others through content or connection , and priority topics they would find engaging and relevant . Compared to national estimates, the prevalence of certain health behaviors among our target sample of adolescents of color differed; 44% of our study sample reported consuming 5 or more servings of fruits and vegetables daily and 39% reported sleeping 8 or more hours per night compared to 15% and 26% of adolescents from the 2017 Youth Risk Behavior Surveillance Survey, respectively [22]. With respect to interest in intervention content on physical fitness, diet, and mental health, our study findings were consistent with a prior study on social media use and mental well-being among participants aged 14-22 years that reported fitness, nutrition, stress, anxiety, and depression as the top 5 topics searched on social media platforms [23]. To date, there is a lack of research on healthy weight management or obesity interventions delivered via social media among adolescents in the United States. A few studies have examined the efficacy of mobile health interventions targeting diet, physical activity, and BMI among adolescents with promising improvements in certain health behaviors, though the vast majority of these interventions are app or text-based, are not delivered via social media, and lack adequate representation of participants of color [24][25][26]. One pilot intervention study targeting weight-related behaviors among primarily White adolescents aged 14-18 years incorporated social media as an intervention component to enhance engagement [27]. Participants in the aforementioned study experienced an average increase in steps, though the majority of participants reported preferring other social media platforms such as Instagram over Facebook for intervention purposes. This body of literature combined with findings from this study highlights gaps in the field in leveraging social media as an intervention modality to promote healthy eating and physical activity among adolescents, particularly those of color. Given the high rates of social media use among adolescents and the prevalence and fast spread of inaccurate health information on social media, the following design considerations, based on our results, may be helpful to guide the development of social media-delivered interventions targeting healthy weight management behaviors among adolescents of color [28]. These include designing content that can be readily disseminated via multiple platforms to reach multiple audiences; matching intervention activities with platforms that are most suited to meet the activity's purpose ; collaborating with adolescent peer leaders to co-design and deliver content to enhance engagement and relatability of content; incorporating frequent microhealth tips; and integrating discussion of physical and mental health topics. Study strengths include the recruitment of adolescents of color who experience disproportionately higher rates of obesity and are underrepresented in health research and the use of quantitative survey and qualitative focus group methodology to understand patterns and preferences for a social media-based intervention targeting healthy weight management behaviors. Qualitative data provided additional context of the reasons behind participants' preferences of certain social media platforms over others, why certain platforms were preferred for a social media-based intervention targeting healthy weight management, and what respondents felt should be included in such an intervention. Study limitations include a relatively small sample size of 101 survey respondents and 20 focus group respondents , where most focus group respondents were female ; cross-sectional assessments, which limit our ability to examine changes over time; the use of self-reported measures, which may be subject to recall and social desirability bias; selection bias ; and convenience sampling, which resulted in a majority Latine sample recruited from Massachusetts and California, thus limiting generalizability of study findings. --- Conclusions Given the near ubiquity and high prevalence of social media use among adolescents and adolescents of color, a social media-delivered intervention has a high potential to reach and engage adolescents of color in healthy weight management behaviors. Findings from this study, along with further partnership with adolescent peer leaders, can be used to begin to inform the choice of platform and development of content and strategies for future social media-delivered interventions for youths of color and subsequent efficacy trials of intervention approaches tailored for this population. --- Conflicts of Interest None declared. --- Multimedia Appendix 1 Focus group guide for 20 adolescents of color participating in a mixed methods pilot social media study. --- XSL • FO RenderX ©Selenne Alatorre, Aviva G Schwarz, Kelsey A Egan, Amanda R Feldman, Marielis Rosa, Monica L Wang. Originally published in JMIR Pediatrics and Parenting , 08.05.2023. This is an open-access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Pediatrics and Parenting, is properly cited. The complete bibliographic information, a link to the original publication on https://pediatrics.jmir.org, as well as this copyright and license information must be included.

Background: Social media holds promise as an intervention platform to engage youths in healthy weight management and target racial inequities in obesity. Objective: This mixed methods study aimed to examine social media habits, preferences, and obesity-related behaviors (eg, diet and physical activity) among adolescents of color and understand preferences for healthy weight management interventions delivered via social media.This mixed methods study is comprised of a cross-sectional web-based survey and a series of digital focus groups. Study participants (English-speaking youths of color ages 14-18 years) were recruited from high schools and youth-based community settings in Massachusetts and California. For surveys, participants were invited to complete an anonymous web-based survey assessing self-reported sociodemographics, social media habits and preferences, health behaviors (diet, physical activity, sleep, and screen time), and height and weight. For focus groups, participants were invited to participate in 45-to 60-minute web-based group discussions assessing social media habits, preferred social media platforms, and preferences for physical activity and nutrition intervention content and delivery. Survey data were analyzed descriptively; focus group transcripts were analyzed using a directed content analysis approach. Results: A total of 101 adolescents completed the survey and 20 adolescents participated in a total of 3 focus groups. Participants reported most frequently using TikTok, followed by Instagram, Snapchat, and Twitter; preference for platform varied by purpose of use (eg, content consumption, connection, or communication). TikTok emerged as the platform of choice as an engaging way to learn about various topics, including desired health information on physical fitness and diet. Conclusions: Findings from this study suggest that social media platforms can be an engaging way to reach adolescents of color. Data will inform future social media-based interventions to engage adolescents of color in healthy weight management content.

mature students, who are the focus of this work. Nevertheless, this participation may have very distinct meanings, such as being enrolled, going to classes, having the same opportunities as so-called 'traditional' colleagues, participating in the governing bodies of higher education institutions, being able to represent oneself and other fellow students on these same bodies, being part of the numerous decision-making processes that affect the life of the institution and of those who work and study there, being represented by peers who seek to advocate for mature students' specific interests, will and needs, among many others. This work focuses on a specific form of student participation through their membership in governing bodies of higher education institutions, in which they represent themselves and other colleagues. There are, however, two aspects that need to be clarified. Firstly, this does not mean that participation is restricted to representation. There are other forms of participation. See, for example, an engagement framework developed by Student Partnerships in Quality Scotland in Scotland . It is a student partnership staircase, with four roles that correspond to increasing levels of involvement: in the first, the student is a mere 'information provider ' , who provides information through questionnaires, class discussions, emails, discussion groups, among others; in the second, the 'actor' collects and analyses contributions ; in the third, the student is recognised as 'expert' in learning ; in the fourth, the 'partner' participates in an 'authentic and constructive dialogue ' . Secondly, representation, or the presence of students in governing bodies, does not necessarily constitute full participation. If deeply unequal power relations are maintained, favouring teachers to the detriment of students, the involvement of these students is merely tokenistic . Even so, in the institution where we carried out this research, student representation, associated with belonging to governing bodies, is an aspect that deserves attention for reasons that we hope this text can highlight. Research on the participation of mature students in governing bodies of higher education institutions and their representation in these same bodies is limited. In this journal, for example, several works have been published about the presence of mature or non-traditional students in higher education , but we did not find any with the specific focus that we propose. The literature that we know of with this focus is scarce. The one that exists does not include any work related to Portugal and tends to justify the lack of participation of mature students in governing bodies with their lack of time , difficulties in combining work, family and study , among other practical and cultural, social and emotional barriers . Despite the importance of ensuring 'that students with particular needs such as parttime students, mature students and international students are represented' , it is as if participation and representation of mature students in higher education were between a rock and a hard place. On the one hand, they 'are far less likely to run for election if they have no visible role models with whom they can identify' . On the other hand, if 'they only represent a specific cohort of students, [this] further [disincentivises] participation amongst those from other groups. ' . The political nature of their presenceand potential impacts -is indeed a 'hard place' in such a way that it is possible to find in the literature an essential tension between the politicising or depoliticising effect of the presence of mature students in higher education. Let us start with depoliticisation. Martin Trow stated that adults 'tend to be less highly politicised and have a more exclusively academic or vocational interest ' . A similar but more developed idea was presented by Manja Klemenčič : A diverse student body is welcoming and enriching to the HE community in many ways. In view of student representation, however, diversity poses a challenge: a more fragmented student body with weaker common bonds has more difficulties to come to consensus on common interests and speak with a united voice. Non-traditional students not only have major obligations outside the academic environment , but also tend to have a stronger vocational orientation. Thus, larger share of these students potentially adds to the de-politicisation of the student body and its representative organisations. In more recent work, the author reinforces this idea: 'Student movement mobilization potential has been profoundly affected by the increasing diversity of student body, which makes it more difficult to establish a collective student identity, shared grievances and shared emotions.' . Chirikov and Gruzdev also refer that: recent studies have shown that growing enrolment in Russian higher education has resulted in a more diverse and less motivated student body, decreased student engagement, and a lack of student participation in university governance . This perspective is disconcerting. Why and how do non-traditional students contribute to depoliticisation? To the decrease in student engagement? Isn't politics precisely the attempt to find consensus among the diversity of opinions, interests and perspectives? To discover 'unity in diversity', a sine qua non condition for improving and constructing 'a substantive, radical democracy', as Freire said . Why is a more homogeneous student body more politicised? However, both Trow and Klemenčič contribute arguments that seem to point in the opposite directionmeaning that diversifying the student body can increase politicisation. According to Klemenčič, the involvement of minority students, through 'diversified, accessible and affordable' methods that effectively reach all students, 'may moderate potentially negative effects of such groups on the cohesive nature of the university environment' . We agree, except for the verb 'may' reservations. We do not doubt that these possible adverse effects can only be counteracted through the participation of these students and all the other students. Trow's perspective, this time, is more complex. In elite higher education institutions, says the author, governance tends to be the responsibility of 'senior professors', while in 'mass higher education' student participation gains centrality . In the latter case, 'students, drawn from more diverse backgrounds and affected by radical political currents, challenge many of the traditional values and assumptions of the university' . Interestingly, this radical policy constitutes a severe institutional risk: 'The breakdown of institutional governance arising out of value dissensus and fiercely politicized conflicts of values and interests tends to weaken the autonomy of an institution ' . It seems to us that more research is needed in this regard. Simplifying and even exaggerating, we are faced with arguments of two types. First, mature students 'do not participate because they do not want to' 'or can't'the result is the same. From this point of view, it seems that nobody prevents them. Second, as they have other things to worry about, mature students are not involved in the academic environment, contributing to the depoliticisation of the student body. Strongly rejecting these two types of arguments, we argue that we should not take it for granted that nobody prevents them and that they depoliticise the university and the student body. This is for two reasons: one of a more practical nature, the other more theoretical, but both dialectically interconnected, as Freire defended. The first reason stems from the experience lived by one of the authors of this text as a mature student with a great desire to participate at various levels in the institution's governanceand with very few adequate opportunities to do so . And who felt that her colleagues, who were members of the faculty and university governing bodies, hardly represented her. It is a reason as fragile as it is robust. Statistically, it may not have any meaning. As a life experience, it is worth everything, 'wet' as it is with feelings, desires, dreams . The second reason is our theoretical position : what matters to us is not so much recognising and validating the specific identity of a group nor just class stratification , but the 'parity of participation', i.e., the possibility or not of 'participating as peers in social life' . We are not interested in the 'mental attitudes' of mature students, nor in justifying their reduced participation with their lack of time, but rather in understanding how injustice is institutionally generated . Thus, 'Overcoming injustice means dismantling institutionalized obstacles that prevent some people from participating on a par with others, as full partners in social interaction' . According to Fraser , 'participatory parity' encompasses three dimensions: redistribution, recognition and representation. The third aspect has received the least attention in Portuguese universities . See, for example, the most recent Bologna Process Implementation Report : Portugal records a positive result regarding measures to support the access of underrepresented groups to higher education and the recognition of prior non-formal and informal learning . It does less well, however, on measures to support the retention and completion of students from under-represented groups . Although these are not specific data on the representation of mature students in higher education , one can see the effort to promote access to higher education among underrepresented groups and even the recognition of non-formal and informal learning, but less so with success in higher education. This is something that the literature has highlighted: access and success are different aspects, as well as increasing and widening participation . If we had to summarise the state of play in just one idea, we would say that research has also focused mainly on these students' access to higher education. The over-23 policy, for example, has promoted, since 2006, the access of mature students to higher education, albeit with differences between institutions, areas of study and prestige of institutions . Despite these differences, an effort to recognise experiential learning can be admitted: the entrance tests include a curriculum assessment, an interview, and a written test. Also, there are institutions that more or less appeal to the life experience of the candidates . This does not mean that redistribution and recognition are resolved; far from it. As far as we know, the social class of students who attend higher education has yet to be precisely known, nor is the possible impact that the over-23 policy has had at this level . Little is also known about the recognition of prior learning, either when these students are selected or throughout their courses, in lessons and at assessment times. Even so, representation is the aspect that has received less attention. So far, we have not found any study in the Portuguese context that refers to it. Returning to Fraser , representation is par excellence the political dimension of justice. The other dimensions also have a political nature, so much so that the first model defined by Fraser was only two-dimensional, composed of redistribution and recognition. The author later realised that the political constituted, even so, a dimension in itself, making her model three-dimensional, i.e., adding representation to the previous dimensions. According to Fraser , representation encompasses three levels, which correspond to an equal number of levels of 'misrepresentation', understood as 'political injustice ' . At the first level, 'representation has the straightforward sense of political voice and democratic accountability' . At this level, when the 'political decision rules wrongly deny some of the included the chance to participate fully' , 'ordinary-political misrepresentation' occurs. At the second level, 'representation is a matter of social belonging' , i.e., who counts as a member? Who is included and who is excluded? The corresponding injustice is called 'misframing,' which means that 'the community's boundaries are drawn in such a way as to wrongly exclude some people from the chance to participate at all in its authorized contests over justice. ' . The third level is meta-political and refers to democratising the 'process by which the frameworks of justice are drawn and revised.' . At this level, injustice is called 'meta-political misrepresentation', with the effect of excluding the 'overwhelming majority of people from participation in the meta-discourses that determine the authoritative division of political space. ' Therefore, based on the perspective of teachers and students who are members of a Portuguese university's governing bodies, this work aims to understand the representation process of mature students. Although it is fundamental to understand the perspective of mature students, this study privileges the institutional perspective, i.e., the way governing body members see the topic. This option has at least three justifications: the first is the experience of one of the authors of this text, as we said before, which shows us the difficulty of participating, despite her desire to do so, and the feeling of not being adequately represented by and in the said governing bodies. The second has to do with the fact that this research was carried out as part of a Master's degree, so the time available required making choices and focusing on what we wanted to know the most. The third is theoretical: like Nancy Fraser , we argue that 'justice pertains by definition to social structures and institutional frameworks. It follows that individual problems become matters of justice if and when they cumulate into a pattern that can be traced to a systemic cause.' Inspired by this author, we could ask at least one question related to each of the three levels of representation: 1) Do the existing procedures and mechanisms 'accord equal voice and fair representation in public decision-making to all members' , namely mature students? 2) Do the 'boundaries of the political community wrongly exclude some who are actually entitled to representation' , i.e., in our case, mature students? 3) Is it democratic or is it being democratised 'the process by which the frameworks of justice are drawn and revised' , i.e., 'new democratic arenas for entertaining arguments about the frame' exist or are being created ? These are our research questions, which we will try to answer based on our data. This is a first exploratory study, of a qualitative nature and with a critical approach. It was submitted and approved by the Ethics Committee of our Faculty and took place in a Portuguese higher education institution. The selection of the governing bodies obeyed only one criterion: to have student representatives in their constitution. To better understand the topic, and after the signature of the informed consent and clarifying any doubts that might exist, we conducted semi-structured interviews with thirteen governing body members: eight students and five faculty members. These bodies are all those that, in this institution, have student representatives. The script included a set of questions about student representation in higher education. We asked if every student is represented or if subgroups of students 'may not feel genuinely representedin all bodies, namely in the one to which the interviewee belonged. We also asked them to share perspectives on the 'over 23' policy, student workers and the concept of 'mature students'. Finally, we questioned how to improve the student representation process. The interviews were fully transcribed, and the names of people and institutions were anonymised. This loss of clarity and detail is unavoidable, nevertheless, to ensure that reversing anonymisation is not possible. For this reason, we cannot provide additional data, either on the organisations or on the interviewees, such as gender, age, and study area. We coded the name of each interviewee under the following logic: the designation 'University' indicates faculty members and students included in the constitution of two governing bodies. In turn, the expression 'Faculty Body' includes faculty members and students of four governing bodies of one Faculty. The designation 'student representative' is used for students included in these governing bodies and two student associations. The codes for the 13 interviewees can be seen in Table 1. Our analysis was inspired by the thematic analysis proposed by Virginia Braun and Victoria Clarke . We began by transcribing, reading and re-reading the interviews, identifying the main ideas; coding the text and collating extracts related to each code; organising the codes into potential themes and sub-themes; reviewing themes and subthemes; and producing our narrative based on the data, the research questions and the theoretical framework, with particular attention to the aspects with which the interviewees showed disagreement and agreement. Next, we present the analysis of four themes: knowledge vs. lack of knowledge about the functioning of governing bodies, functioning logic of governing bodies, mature students: conceptions and preconceptions, and non-mature representation of mature students. Most of the participants revealed that they were generally familiar with the structure of a higher education institution and distinguished the institutional bodies provided for in the Legal Regime of Higher Education Institutions and student representative bodies, such as the Student Associations of each faculty. These Student Associations are generally affiliated with Academic Federations; some are part of the university's Senate, an advisory body. There are the representative governing bodies established by law and, outside these institutional bodies, there is the Student Association, which is the body par excellence for student participation that best represents the student community and plays an important role in academic life. Among the students, the discomfort they felt while answering was evident because, although they were members of a governing body, they recognised that they did not know the governing bodies in which they did not participate: 'I can tell you about the body in which I am a member, I don't know as it is in others' . This data is critical, given that access to information is, according to Klemenčič , 'the basis for all subsequent levels of participation'. If this does not happen, student participation is expected to be compromised. Moreover, the institutional framework is only known by those who have the opportunity to be members of governing bodies. In that case, it is expected that most students and even some staff, who do not have this opportunity, are unaware of such a frameworkwhich most likely constitutes a significant obstacle to broader participation. In comparison, the faculty members tended to be more confident about the definition of the competencies of the governing body in which they were participating, as well as to expose an overall vision regarding the various governing bodies of the institution. Although the organisation and its governing bodies are presented, as usual, on the institution's websites, two faculty members mentioned that higher education institutions should have a more active role in promoting this organisational knowledge, contrary to the current scenario in which, according to them, more and more students go to the Faculty to take classes, not showing much interest in participating in the extracurricular activities that the institution promotes. This is, moreover, a problem often described in the literature. It should be said that student participation is reduced, not only among mature students but among students in general: 'the majority of students rarely get politically engaged in student protests or student governments, even if this involves only casting a vote in student elections.' . Among the obstacles to student participation , interviewees mentioned above all the lack of knowledge about the functioning of governing bodies, the difficulty of reconciling study with extracurricular activities and the absence, markedly neoliberal, of a culture of student participation. 'Our young people were born into neoliberalism and are not used to collective participation. Students do not want to participate in these activities' . Most participants believed there could be greater student participation in governing bodies, if institutions were more proactive about this lack of knowledge about such a complex organisational structure and sought to find strategies to mitigate this lack of knowledge. Two examples have been suggested. One would be the early and regular holding of clarification sessions on the existing governing bodies, their functioning, competencies and the importance of students being part of some of these bodies, such as the Council of Representatives, the General Council and the Pedagogical Council, which is the only parity governing body, i.e., it has an equal number of faculty and student representatives. 'The Pedagogical Council is a body where the presence of students is very important and where pedagogical issues are discussed a lot and where very important decisions are made for the lives of students' . To clarify the doubts that often exist about the electoral process, we think that it would be essential that these sessions occur before each election so that students are motivated to participate, either as voters or as candidates for student representatives. Another example would be, within the scope of academic integration activities promoted by the Students' Association, raising awareness of the participation of all students in various aspects of academic life: electoral processes, student representation bodies, filling out pedagogical surveys to evaluate teachers and courses, research communities of practice, various initiatives of the University for communication with the surrounding community, among others. As mentioned by most participants, the participation rate of students in electoral processes for the constitution of governing bodies is relatively low: 'The participation rate is almost zero on the part of students. As much as the governing bodies want to streamline this issue, they cannot oblige students to participate. Students do not realise their importance and influence' . Regarding the functioning of the governing bodies, difficulties were mentioned in finding available times to bring together teachers and students, aggravated by everyone's work overload. Most interviewees view participation in governing bodies as extra work. 'The attendance that should exist in these joint meetings is soon impaired due to the overload of the professors' academic work and the workload of the various courses that the students have' . It is not surprising, therefore, that the governing bodies act according to a reactive and emergency logic, i.e., reacting and trying to solve one or more problems that have been reported: 'When there are problems, one acts like first-line firefighters who act in the immediate to put out the fires, so that the problem can also be solved immediately' . The bodies remain passive if they are not informed that the students face one or more problems. All participants also recognised that the COVID-19 pandemic led to better knowledge among students of these representation structures and their importance due to the numerous difficulties that disturbed daily academic life at a pedagogical and financial level. 'There was much concern for students, especially during the pandemic, because, in the face of the various problems that were arising, it almost forced the students to know which governing body they should refer to' . We argue that the governing bodies' performance should be more active, favouring a preventive logic. However, for that to happen, other conditions would have to be verified, namely the work overload of teachers and students. Information could be more actively sought not only on existing problems in the student community, namely among underrepresented groups of students, but also on what is done well and what is worth being known and recognised. Instead of waiting passively for this information, activities could be organised to reach students more effectively, such as questionnaires or interviews with students, face-to-face or online, opening a suggestion box, setting a time such as 'coffee time' to allow students to talk informally about a wide range of academic subjects. As Day points out, 'The "hyper-diversity" of the student body means student leaders are looking at new ways of engaging student opinion, through informal forums, surveys, focus groups and reaction [through] new media.' This 'consultation' is a fundamental level of participation . More or less explicitly, the interviewees often saw mature students as burdened with difficulties and needs. The examples of what they supposedly lack are many and varied: adaptation, social integration, time for work, family and university, understanding curriculum content, relearning academic language, attendance at classes, participation in group or peer work, study and work habits, time devoted to autonomous work. Below, we present two excerpts, among many others that could serve as examples: The over 23 [students] find it difficult to integrate themselves in the face of the demands placed on them by entering higher education, and sometimes there are many difficulties. But these are my perceptions. Re-entering an academic life requires a double effort to reconcile family, work, and academic life. The relearning of another academic language, which is required in academic life from undergraduate students, makes these students reframe what they know through everyday experience through other concepts and perspectives, etc. The availability of mind and time to dedicate themselves to the academic cause is very different from that of a fulltime student. We agree that this group of students generally has some characteristics, of which some difficulties and specific needs are examples. However, the various deficits in the interviewees' speech outweigh the positive aspects. More than that, people not only have these deficits but also become these deficits . In its complexity, their identity is reduced to the 'minority' characteristic. In the interviews, disadvantages were incomparably more valued than maturity, experience, and intrinsic motivation. Interestingly, there are several examples in which even praise is associated with reinforcing prejudice and stereotypes about mature students. Knowledge is not hampered by having a few more wrinkles. This public may have more difficulty concerning operating memory, working memory, but this is part of the ageing process. Higher education is only adapted to ordinary students of a particular age group and needs to change urgently. In the interviews, discrimination and prejudice sometimes appeared more or less disguised, even by those who defended an urgent change in higher education. Note the power of the scientific 'order of discourse' ), i.e., how scientific constructs are brought as an argument of authority. We doubt that the differences between mature and non-mature students' 'operating memory' and 'working memory' are evidence-based. And even if it were, how much negative impact does a stereotype have if we can only point it out without doing anything to make it less disadvantageous? Very present in these speeches is the notion of inadequacy and non-compliance... Isn't this a prejudiced view? Could it be that the difficulty of complying with 'academic rules and habits' has reasons other than idiosyncratic aspects of an individual nature? In these interviews, difficulties and needs are usually attributed to the personto their identity as a 'minority' , which is thus essentialisedand rarely to structural, social aspects. Let's put the difficulties on two levels: first, the sociability that I have witnessed in the relationship that is not always very positive between the so-called traditional students and those that appear in contests for those over 23; secondly, often these new publics, because they had a different training path, it happens that in an initial phase they have some difficulties in adapting their activities, what they produce and even their performance to academic rules and habits. I notice this difficulty. However, the academic success of some students is evident. One of the most frequent examples of difficulty experienced by mature students has to do with time management and scheduling compatibility. As we see it, this structural constraint does not result from incapacity or personal inadequacy but rather from the need to combine work and family with academic life. Thus, some interviewees suggested the creation of post-work schedules in higher education institutions to promote the participation of these students: I believe there are currently many more student workers than in the past. I would like to see a more active intervention by these students, perhaps it is time to create an after-work schedule, to adjust the situation of this public. Even when valued by some interviewees, the students' biographical paths were seen from a particular individual perspective, with no clear examples of awareness -which is the first step in the 'conscientização' process, as Freire ) mentionsregarding the collective, common aspects to the diverse, unique and unrepeatable individual stories. These students enter a new world with very different study methods. They have already lost the habit of studying, the habit of concentrating on listening, but on the other hand they have the added value of having a greater life experience, which in my perspective it makes perfect sense to be mobilised in any area. From our perspective, this prejudiced view of mature students, highlighting their difficulties and needs, is an aspect that deserves attention, given that this assumption of various deficits does nothing to help think about the participation and representation of mature students in higher education. If they are perceived as less 'capable', it is likely that they will end up being made invisible. Although less frequently, we also heard in the interviews a very different perspective of recognising what 'over 23' students bring positively and how they can enrich academic life. 'These students, after having gathered life and professional experiences, constitute an asset in enriching the diversity of the student public' . In the interviews, we perceived the strangeness and/or resistance with which this theme was received by the interviewees, either because they had never thought about it or because they believed that it is up to the existing mechanisms to ensure the representation of all students or even because the solution could be somewhere… in a particular institutional limbo, as we shall explain. Although the diversity of the student population is recognised, as we saw before, the responsibility is attributed to the student representatives, given their extraordinary qualities and characteristics . It is up to them to reach everyone equally. When the year's representatives are elected, it is always reiterated that this person must have specific characteristics and qualities: attention to the other, a relationship with the other, empathy, active listening, etc. This year's representative represents the diversity of all colleagues. Blaming student representatives poses several problems. We highlight two: it constitutes, firstly, an attempt to exempt the institution from that same responsibility since the issue is resolved based on the superpowers of these chosen students; secondly, it is hardly credible that these superpowers exist, that a few personal qualities are enough actually to represent all students, in their diversity. When I contact the year representative, I assume that he [sic] is there representing all the students, but I don't know if, in fact, there is more attention to some than to others. I'm thinking about this for the first time. These representatives are elected by peers, so from the beginning, they should represent the entire student population. I am thinking that a representative, a regular student who has completed his [sic] formal career without a break, might not be as sensitive to the needs of other types of students. In the case of mature students, it is often a matter of representation by non-mature students. We intentionally reverse the usual logic, according to which these students are designated by what they are not, i.e., 'non-traditional', as if they were less than younger, 'traditional' peers who come straight from secondary school. Now, as mentioned by McStravock , Recognising this diversity means ensuring that mechanisms are in place to capture the experiences of all members of the student community and avoiding tokenism or one size fits all approaches that often favour the voices of more dominant student groups. We could hear, however, another proposal, this one of a more collective and institutional nature, which would involve the creation of a transversal association, bringing together representatives of 'minority' students from the different faculties of the University. These students should unite and form a kind of transversal association, which would be constituted as a pressure group and could have the rights and duties of a student association. All faculties have a student association, a transversal group could be set up to commit to mobilising this public. In each faculty, there is little adult public, a group of student representatives could be created at the University level to defend the interests and difficulties of these students, as by law I doubt that this will ever be done. . As we understand it, this proposal is based on a set of assumptions worth underlining. First, the responsibility remains with the students: it is up to them to unite and organise themselves. The institution remains exempt from responsibility. The professors too, to such an extent that, according to some interviewees, mature students should be interviewed instead of professors who are members of governing bodies. Secondly, if it is necessary to create a transversal association to represent these subgroups of students, it is because the student representation that currently exists does not really defend the interests of all students. Furthermore, even if it is necessary to create a new representation body, it is because it is understood that the existing ones cannot, or eventually do not want to, welcome representatives of the so-called 'minorities'. Thirdly, this association above faculties would run severe risks of hovering in an institutional limbo. It should be remembered that, in this institution, the different faculties present incomparable situations regarding the percentage of 'over 23' students. They are different contexts, so it is unlikely that this supra-institutional structure could impact each faculty. Given the high abstention of students in the various elections and the reduced adherence to activities carried out by student associations, as stressed by the interviewees, it is not clear how this transversal association, outside the institution where they study could facilitate the participation of mature students. Is this not also a question of a discriminatory solution? Instead of bringing underrepresented students to the centre of the discussion, there would be a risk of marginalising them, limiting them to their 'minority' and not promoting dialogue between these students and the rest of the student population. This proposal deserves deep reflection. It seems to constitute an 'affirmative' policy, 'which aims to valorise devalued identities' . Fraser criticised this approach for essentialising differences between groups. Instead of 'identity politics', she defended 'status equality', since In some cases, claimants may need to affirm devalued aspects of their identity; in other cases they may need to unburden themselves of excessive 'difference' that others have foisted on them and to emphasize their common humanity; and in still other cases they may need to deconstruct the very terms in which common sense differences are typically elaborated. Would this structure guarantee equal rights to all students? Or would the political division put 'minority' students at a disadvantage? Would they run the risk of 'political death', being transformed into 'non-persons with respect for justice', becoming 'objects of charity or benevolence' ? In another excerpt, it is possible to perceive this paternalistic logic underlying this transversal structure: the 'minority' students should organise themselves to bring their 'difficulties and needs' to the University, which will do something for their 'benefit'. Student movements are characterised by their concern for defending the interests of all students . In practice, and often, representation does not guarantee the fulfilment of the will of all students but rather that of a majority. The concepts of minority and majority also deserve critical analysis. According to Freire , the true minority is the elite that remains in power, reserving, among others, the power to nominate others, namely as 'minorities': The so-called minorities, for example, need to recognise that they are actually the majority. The way to assume oneself as a majority is to work on the similarities among themselves and not only the differences and thus create unity in diversity, outside of which I do not see how to improve and even how to build a substantive, radical democracy . From this point of view, by gathering all the 'minorities' discriminated against by one or several factors -social class, 'race' and 'ethnicity', gender, and age, among others -, we obtain a majority, unitary in its diversity. Usually, and without this effort to unite, the 'minorities' do not perceive themselves as the majority they really are , p. 277). In other words, if we consider not only age but other factors of discrimination, the composition of the majority and minorities will likely be mixed up. In higher education, mature students are often 'minorities', but if associated with other 'minorities', they are likely to constitute a new majority. Examples of other 'minorities' are the following: student workers, ethnic and migrant 'minorities', disabled students, women, first-generation students, LGBTQIA+, working-class students, among others. Throughout the research, we noticed some resistancefor example, in some of the interviews we didand faced the criticism of colleagues, according to whom we should have been more concerned with participation than the representation of mature students in higher education. We accept that this criticism is only fair partly and allows us to clarify our point of view. It seems clear that participation is broader than representation. Therefore, several dimensions related to these students' participation must be considered, for example in the student association, classes, research groups, and volunteering, among many other initiatives. Furthermore, and we hope to have made this clear throughout this text, our idea is not to propose a reinforcement of the representation of mature students in their absence, i.e., only non-mature students representing them in the different governing bodies of higher education institutions. We believe that it is here, moreover, that the criticism becomes unfair. We do not see participation and representation as binary either/or dimensions. On the contrary, in our institutions, representation is a very significant form of student participation in the governance of institutions. It is potentially one of the most powerful, if the experience goes beyond a still 'important symbolic integration' and allows them to express their opinion, discuss, vote, participate in successive decision-making… So, why are there practically no mature students with this power to represent themselves and other students in governing bodies? What is the reason for ignoring them, for the resistance? We agree with Fragoso et al. when they say that the 'over 23' policy and the consequent population diversification constituted 'a very important step towards the democratisation of higher education in Portugal'. Our data show, however, that many other steps must be taken towards democratisation. Examples are the promotion of a de facto knowledge of the higher education institutions and their governing bodies, a more preventive functioning logic and more diverse and appropriate forms of consultation, the demystification of prejudices concerning mature students and the fight against ageism and any form of discrimination, as well as research, reflection and discussion of student representation, without forgetting the possibility for mature students and other under-represented groups to participate as peers in university life. It is true that, as this is an exploratory work, it has several limitations, among which we highlight two that seem most important. The first has to do with the volume of data we collected. Even though we cannot guarantee that we have reached the saturation point, they seem, even so, data worthy of attention. More research is needed on this topic, collecting more data from other institutions and listening to students . The second concerns how much remains to be explored regarding the heuristic power of Fraser's theoretical model for understanding this topic. At this point, it is important to return to the three research questions with which we closed the introduction to this work. First, we asked whether mature students have 'equal voice' and 'fair representation' . With some confidence, we can say that the existing mechanisms and procedures do not accord equal voice and fair representation to mature students. Second, we asked whether the boundaries of the political community exclude mature students. We can say mature students are wrongly excluded, although they are supposedly 'entitled to representation' . Nonetheless, it is unclear how boundarysetting contributes to this, as this exclusion is often justified by the mature students' lack of time, making it impossible for them to attend meetings, for example. Nor is it clear whether they are denied 'the chance to participate fully' or, more than that, whether they are excluded 'from the chance to participate at all' . The third question concerned the more or less democratic nature of the processes for creating and revising the frameworks of justice, as well as the existence or not of spaces to think about and discuss the framework itself . This question leaves us with even more doubts. See the example of the proposal to create a transversal structure. If it fails, for the reasons we explained earlier, what would it take to constitute a transformative movement that would demand the creation of 'new democratic arenas for entertaining arguments' about 'the process by which the frameworks of justice are drawn and revised' ? As we said, these can be arenas other than the governing bodies. Paraphrasing George Orwell's 'Animal Farm' famous principle, we would say that we are all equal, but some are more equal than others. Mature students have some characteristics that are different from other students: age, experience, regime through which they access higher education, work… As we noted earlier, based on Freire, the 'minorities' together constitute the majority. So, what matters is not so much recognising differences but ensuring that everyone can fully participate , has the opportunity to represent other students, and all are truly part of the political community that the university constitutes. This would benefit not only the underrepresented students but also the other students and the community, which would become more democratic and fairer.

With this text, we try to understand ifand if so, howmature students are represented by and in the governing bodies of higher education institutions. With a theoretical framework that values above all the institutional dimension, we carried out thirteen semistructured interviews with students and faculty members who are part of the various governing bodies with student representation of a Portuguese higher education institution. The data show that (i) the functioning of these bodies tends to be known only by the students who participate in them, (ii) the bodies usually react to, rather than prevent, the problems that arise, (iii) mature students are perceived as a source of 'difficulties ' and 'needs', and (iv) student representation in governing bodies does not seem to fairly and equitably represent all students, and some specificities of mature students (among other underrepresented groups) seem to be made invisible. mature students, student representation, student participation, higher education, justice Widening access and participation in higher education: this is a frequently repeated expression in the literature, which reflects a growing diversity of the student population and an increase in the presence of underrepresented groups in higher education, namely

Introduction Socioeconomic disparities in health and mortality are perhaps the most fundamental of social inequalities. Educational attainment is a particularly profound predictor of length of life, now surpassing both race and gender in importance in the United States. More troubling is that educational differences in life expectancy have widened dramatically since the 1980s, across all major race and gender groups, and that low-educated white Americans are now seeing absolute declines in longevity . Furthermore, those with less than a high school diploma exhibit higher lifespan variability and can expect greater uncertainty in their time of death . By contrast, college-educated Americans live longer, on average, and exhibit greater compression of mortality, with deaths narrowly concentrated at the upper tail of the age distribution-a pattern similarly observed in multiple European countries . Building on prior research, this study extends the discussion on educational disparities in adult mortality beyond differences in what Cheung and colleagues term "central longevity indicators"-mean, median, and modal age at death-to include disparities in lifespan variation. The motivation is twofold. First, it facilitates a more nuanced understanding of lifespan inequality and its underlying causes. Higher lifespan variation reflects greater uncertainty in the expected time of death from an individual standpoint and greater heterogeneity in health from a population perspective . All else being equal, increasing lifespan variation often corresponds to an increasing proportion of premature and potentially preventable deaths and should therefore be of interest to both mortality researchers and policy makers. Second, documenting trends in both life expectancy and lifespan variation can provide insight into future mortality scenarios of both advantaged and disadvantaged groups at the subnational level. The scenarios most often considered for the population as a whole are mortality compression ) and translation . Yet, neither of those scenarios has been evaluated for different socioeconomic strata in the United States, particularly over time. Adopting a multidimensional approach to lifespan inequality, this is the first study to reveal trends in both life expectancy and lifespan variation by educational attainment, over a two-decade period, for major race and gender 1 groups in the United States. The findings replicate and revisit important facts concerning recent trends in life expectancy-namely, that educational disparities are widening among all major gender and race groups and that non-Hispanic white women with fewer than 12 years of schooling are increasingly and dramatically worse off in absolute terms. More surprising are trends in lifespan variation. This study finds that between 1990 and 2010, variation in age at death increased among high school-educated Americans in spite of modest gains in life expectancy; at the same time, those with at least some college education have seen tremendous improvements in life expectancy coupled with a steady, record-low variation in age at death. Among women in particular, educational disparities in lifespan variation have become so important that they now approach or even surpass disparities in life expectancy. Overall, these patterns defy the notion that low-and high school-educated Americans are merely lagging behind their college-educated counterparts, as one might conclude from observing trends in life expectancy alone. Documenting educational differences in the age-at-death distribution requires sample sizes exceeding most survey data, especially when sought in repeated cross-sections. The National Vital Statistics System remains the single most comprehensive source of information on U.S. mortality but suffers from wellknown limitations concerning education reporting on death certificates . Therefore, before any empirical investigation is pursued, special attention must be given to missing and potentially misreported information on educational attainment in the vital registry. To improve on prior estimates, I develop a unique imputation method to handle missing data in the vital registry, drawing on all available information from observed death records as well as the educational composition of the census population. In summary, I argue that social disparities in lifespan variation constitute a unique dimension of inequality and, when examined along trends in life expectancy, point to diverging mortality scenarios among educational attainment groups in the United States. This study therefore has three aims: 1. Document change in life expectancy and lifespan variation in the United States from 1990 to 2010 by educational attainment, specific to race and gender subgroups. 2. Examine the relative contribution of differences in means and differences in variances to overall lifespan inequality . 3. Evaluate whether college-educated Americans exhibit mortality compression or translation, and whether low and high school-educated Americans are following in the former's footsteps or show diverging trajectories in adult mortality. --- Educational Disparities in Adult Mortality Differences in Adult Life Expectancy One of the most robust and consistent findings in the social sciences is the association between education and adult mortality. Highly educated Americans are subjected to lower mortality rates and consequently have a higher life expectancy than their lesseducated counterparts . The education-mortality gradient is not only pervasive, spanning multiple race-gender groups and most preventable causes of death , but also widening over time and across successive birth cohorts . A recent study further suggested that low-educated, non-Hispanic white Americans-those with fewer than 12 years of schooling-have suffered absolute declines in adult life expectancy in recent decades . Using data from the National Vital Statistics System, that study showed that life expectancy at age 25, e 25 o , declined from 47 to 43.6 years among low-educated white men and from 54.5 to 49.2 years among low-educated white women between 1990 and 2008. By contrast, evidence from the National Health Interview Survey centered on the same period suggests that mortality at ages 45-84 increased among low-educated white women but not among low-educated white men . Both studies agreed, however, that educational disparities between low-and college-educated whites have widened. The educational gap in e 25 o increased from 5.1 to 13.2 years among white men and from 1.9 to 10.5 years among white women -seemingly phenomenal increases in less than two decades. Educational disparities in adult life expectancy also grew among blacks, albeit to a lesser extent, but no absolute decline was observed among blacks with fewer than 12 years of schooling. Although the widening of educational disparities in adult life expectancy is alarming, several scholars have questioned the causal nature of this association . The expansion of education in American society over the past century rendered the low-educated increasingly select, whereas the college-educated have become less positively select . The change in educational composition may explain, at least in part, the widening of health disparities . Other scholars, however, have emphasized that the risk of mortality diminishes with each additional year of schooling, net of credentials , and that the protective effect of education grew over time in spite of decreasing positive selection among the college-educated . Leaving the causal debate aside, the purpose of this study is to explicate the multiple dimensions of lifespan inequality across educational attainment groups. First, I rely on U.S. vital statistics data to replicate and revisit results reported by Olshansky and colleagues concerning recent trends in e 25 o by educational attainment. Using a slightly modified education categorization scheme and a novel method for missing data imputation, I find that both trends-widening educational disparities and also absolute declines in life expectancy among the low-educated-are clearly evident, albeit attenuated compared with those previously reported. In addition to new estimates of e 25 o , this study documents corresponding disparities in lifespan variation and evaluates their importance relative to those in life expectancy. --- Differences in Lifespan Variation Although group differences in life expectancy constitute the primary and most commonly documented form of lifespan inequality, scholars are increasingly shifting their attention to various measures of lifespan variation and their characteristics . Edwards and Tuljapurkar showed that S 10 , the standard deviation of age at death conditional on survival to age 10, is both informative and distinct from life expectancy as a measure of lifespan inequality. Their study found that around 1981, S 10 was 2.1 years lower among high school-educated Americans than among those with less than a high school diploma . Although trends in lifespan variation depend on the age x on which S x is conditioned , educational disparities are similarly evident at older ages and in other lowmortality countries. Averaging across 10 European countries in the 1990s, van Raalte and colleagues found educational differences in S 35 amounting to 1.5 years among men and 1.4 years among women. They concluded that an excess of premature deaths from circulatory diseases, neoplasms, and external causes was largely responsible for higher lifespan variation among the low-educated. Emphasizing variation in old-age mortality, other scholars focused instead on the standard deviation around or above the modal age at death . Still others adopted the Gini coefficient and Theil's index to examine disparities in the distribution of age at death . Regardless of the measure used, low-education groups consistently exhibit larger variation in age at death compared with their highly educated counterparts . In this study, I measure lifespan variation using S 25 precisely because it captures premature as well as old-age mortality. Conditioning on survival to age 25 ensures that most educational attainment, at least at the college level, is already completed. In addition, I use the Kullback-Leibler divergence to evaluate differences across the entire age-at-death distribution and decompose them into contributions from differences in means and differences in variances. A formal definition of the latter follows in the Methodology section. --- Why Variation Matters --- Heterogeneity and Uncertainty The importance of reducing educational differences in life expectancy is self-evident. But why is tackling other dimensions of lifespan inequality-and, specifically, lifespan variation-so important? Measures of variation play both descriptive and probabilistic roles in population studies . Descriptively, variation measures the spread or dispersion of observations around some central value; probabilistically, variation characterizes a random variable and therefore reflects the uncertainty associated with an individual lifespan. I argue that both interpretations carry relevant information for demographers and policy makers alike. First, larger variation in age at death implies greater heterogeneity in underlying population health. Highly educated individuals command greater material and nonmaterial resources, which in turn facilitate access to healthier lifestyles and environments . In the aggregate, the capacity to optimize health over the life course translates into lower dispersion in the age-at-death distribution relative to subpopulations with fewer resources . Yet, trends in lifespan variation within education groups are equally informative because they summarize changes in underlying age-specific mortality rates. Averting deaths below the youngold threshold age, the age separating early from late deaths , reduces lifespan variation; averting deaths above the threshold age increases variation. In other words, increasing values of S 25 over time correspond to an increase in premature deaths, a disproportionate decline in old-age mortality, or both . Preventing premature deaths, on the other hand, contributes to significant gains in life expectancy as well as greater equality in individual lifespans . Second, from a probabilistic standpoint, larger variation corresponds to a higher degree of uncertainty in the individual length of life. Edwards modeled the economic value of lifespan uncertainty and estimated that the average American would trade roughly one-half year in life expectancy in return for S 10 that is one year lower. But how do people really think and behave? Current evidence suggests that individuals adjust their subjective survival expectations following parental or spousal loss , that survival expectations vary by socioeconomic status and predict actual mortality , and that individuals base their economic decisions and retirement plans on those expectations . However, far less is known about the effect of lifespan uncertainty, which is especially onerous among low-educated Americans, on lifelong decision making and the outcomes of those decisions across multiple life domains. This topic not only is ripe for future research but also lies at the heart of population studies, which have long assumed that individuals are aware of demographic reality and change their behavior accordingly . In fact, this exact reasoning underlies classic demographic transition theory, whereby perceived improvements in child survival lower the need for parents' insurance and replacement strategies and therefore drive fertility decline . In this respect, lifespan variation constitutes a fundamental quantity in demographic research. Although group disparities in lifespan variation reflect inequality at the population level and differential uncertainty at the individual level, long-term trends in variation can also shed light on diverging mortality scenarios across educational attainment groups. --- Future Mortality Scenarios Demographers have long contemplated possible scenarios for the future of human mortality . Fries argued that variation in age-at-death will decline as life expectancy approaches the biological limit to human lifespan-a scenario dubbed "the compression of mortality." Recent evidence suggests, however, that the compression of mortality in high-income countries has slowed down or even stalled since the 1950s, whether measured via S 10 or the standard deviation about the modal age at death . In light of these findings, scholars have gradually advanced an alternative scenario of mortality translation whereby central longevity indicators will continue to increase while lifespan variation remains constant . In other words, the age-at-death distribution will retain its shape as it shifts to older ages . To date, both scenarios have generally been considered for low-mortality countries as a whole. It remains to be seen whether country-level mortality trends are equally shared by subnational socioeconomic strata and, specifically, by various educational attainment groups. Although mortality compression may characterize some education groups, mortality translation might better describe others. Given recent declines in life expectancy among low-educated white Americans, it is clear that certain groups do not partake in either of those favorable scenarios. Yet, several questions remain unanswered. The first relates to the quality of estimates based on U.S. vital statistics. Second, although educational disparities in life expectancy have been studied over time, less is known about trends and disparities in lifespan variation. All evidence from the United States has relied on cross-sectional surveys limited to non-Hispanic whites. Third, temporal trends in lifespan variation can discriminate between competing mortality scenarios among the most socioeconomically advantaged Americans-and suggest new scenarios among less-advantaged groups-that are otherwise not captured by trends in life expectancy alone. Most importantly, evaluating mortality scenarios separately for each educational attainment group will answer whether low-educated and even high school-educated Americans are simply following in the footsteps of the college-educated, albeit at a slower pace, or instead are following alternate and diverging trajectories. --- Methodology Data The basis for all subsequent analyses begins with age-specific mortality rates, with death counts in the numerator and person-years of exposure in the denominator. Allcause death counts were derived from the U.S. Multiple Cause of Death public use files in select census years-1990, 2000, and 2010-and stratified by age, gender, race, and educational attainment. The study period begins in 1990 because educational attainment was not recorded on death certificates nationwide prior to 1989 . In the denominator, midyear population estimates were derived from the 5 % Integrated Public Use Microdata Sample in respective census years. Although education reporting on death certificates suffers from well-known limitations-namely, that educational attainment is reported by someone other than the deceased and therefore heaped at 12 years from both lower and higher levels of education -it remains the single most comprehensive data source on U.S. mortality. Furthermore, it is one of the few data sources rich enough to document fine-grained changes in the adult age-at-death distribution by race, gender, and educational attainment. In both the numerator and denominator data sources, age was recoded to five-year groups starting at 25-29 and ending with an open interval at 90+. Race was categorized as non-Hispanic white and black, excluding other race categories and persons of Hispanic origin because of small death counts or poor reporting . Because the 2000 and 2010 censuses allowed for multiple-race categorization, whereas vital statistics continue to follow single-race categorization, counts from the former were adjusted to match the National Center for Health Statistics' bridged-race population estimates in respective years ). Nationally, race-bridging appears to have only a minor impact on white and black population estimates, adding as much as 0.5 % and 2.5 % to single race counts, respectively, in the 2000 census . In the MCD data, educational attainment is classified in single years ranging from zero to five or more years of college. However, in 2003, educational attainment was reclassified on death certificates from single years to completed degrees. Thirty-four states and the District of Columbia adopted the new classification system by 2010, with the remaining 16 states using the old classification . To maintain consistency over time, I translated degree categories into completed years of schooling. Most importantly, the new classification collapses "12th grade, no diploma" with the 9-12 years category, leaving high school graduates and general equivalency degree holders in a separate category. Ignoring the change in classification overestimates the number of deaths among the least-educated while undercounting deaths in the 12 years category. Therefore, for 2010, I reallocated deaths in the 9-12 years group to 0-11 and 12 years proportional to their relative size in the atrisk population by age, gender, and race . This approach is likely conservative and accounts for departures from previously published estimates. Next, I recoded educational attainment in the census data to match the MCD classification of completed years of schooling . All categories below 12 years were recoded as 0-11. Those with more than one year of college education or an associate's degree were classified as 13-15, and those with a bachelor's degree or higher were placed in the 16+ category. Finally, all those who reported completing grade 12 , obtaining a GED, or completing "some college credit, but less than one year" were coded as 12 years. Given that those with some college education but no degree are significantly more likely to be reported as high school graduates on death certificates , and probably more so if they had completed less than a full year of college, I included them in the 12 years category .2 This classification aims to reduce non-sampling error due to education misreporting; it also departs from the categorization used by Olshansky and colleagues and explains much of the discrepancy between our estimates . In effect, it serves to inflate the denominator for the 12 years category and hence reduce mortality rates for that group at the expense of the 13-15 category. --- Missing Data Imputation The MCD suffers from a significant amount of missing data on educational attainment and, to a lesser extent, on Hispanic origin. In 1990, seven states did not report educational attainment on death certificates, and the remaining states had an average of 10.0 % missing information. By 2000, only three states failed to report altogether, and the level of missing data among all other states declined to an average of 4.0 %. Information on state of occurrence is absent from the 2010 MCD public use file; by 2010, however, all states reported educational attainment, and missing information declined to 2.3 % nationally. Similarly, three states neglected to report Hispanic origin in 1990, with reporting improving dramatically in 2000 and 2010. Because I exclude Hispanics from all subsequent analyses, the imputation of Hispanic origin serves only to allocate unclassified deaths to non-Hispanic groups. This number amounts to nearly 100,000 deaths in 1990 and is particularly important to include when estimating mortality rates where the numerator and denominator are unlinked. Imputation of Hispanic origin in the MCD was based on the proportion of non-Hispanics in the census population by gender; race; age; and, where missingness was especially high, by state of occurrence. 3 Because Hispanics represent a small minority among older U.S. cohorts, imputation is unlikely to jeopardize results for the non-Hispanic majority. On the other hand, estimates for Hispanics would be greatly impacted by underreporting and are therefore not pursued in this study. Although only the numerator had cases with missing educational attainment, the denominator can nonetheless prove useful in imputing the former. Bayes' rule makes this relationship clear: p EducationjDeath; X ð Þ ¼ p DeathjEducation; X ð Þ ⋅p EducationjX ð Þ ⋅ 1 p DeathjX ð Þ ;ð1Þ such that the distribution of education in the vital registry, on the left side of Eq. , depends on three terms on the right side: the probability of mortality conditional on educational attainment; the marginal distribution of education in the at-risk population; and the marginal distribution of mortality. This relationship can be further conditioned on X, a vector of covariates including age group, race, gender, and state of occurrence. Although Eq. describes a mathematical identity, it can also be used as an imputation device where each component is estimated separately. This approach takes advantage of the fact that for some quantities, population data are practically complete, whereas other quantities involve missing information and must be estimated. Because p depends only on the at-risk population and p does not depend on education, both can be derived from fully observed information. 4 On the other hand, p depends on missing data, as per the original problem, and has to be estimated. I estimate this quantity at the national level using states with nearly complete data-less than 10 % missing-which follows the convention used by official National Center for Health Statistics publications . Using Eq. , I could then estimate p and the distribution of educational attainment among those who have died , and imputed missing values by randomly drawing from it conditional on age, race, gender, and state of occurrence. 5 The last step was repeated 10 times, averaging death counts across iterations to yield the final estimates , although differences between iterations were negligible. This imputation approach is preferable to other methods6 because it maximizes the use of available information from both the numerator and denominator. Essentially, it assumes that the relationship between education and mortality is equivalent among observed and unobserved cases, weighted by the educational composition and overall level of mortality in each age-gender-race subgroup and state of occurrence-a strategy that is particularly useful in states with a high proportion of missing information. --- Methods Following missing data imputation, I estimated age-gender-race-education-specific mortality rates as input for standard period life tables. To derive exact age-at-death distributions, I interpolated five-year log-mortality rates to single years using natural cubic splines with n -2 knots, where n is the number of life-table age groups . This approach was used to ensure minimal departure from observed data, as a log-linear model might impose, yielding e 25 o estimates that are comparable with the original five-year life tables. The smoothed age-at-death distributions depicted in Fig. 1 , equivalent to the d x column in life table notation, were the basis for all subsequent calculations . Measuring differences across the entire adult age-at-death distribution is less intuitive than comparing particular moments, such as life expectancy or variance. Perhaps the most common measure of distributional divergence, stemming from information theory , is the Kullback-Leibler divergence . It takes the form KLD p 0 ; p 1 ð Þ¼ Z ∞ -∞ p 0 x ð Þlog p 0 x ð Þ p 1 x ð Þ dx;ð2Þ where p 0 is the probability function of the reference group, and p 1 is the probability function of the comparison group. 7 The KLD exhibits several useful properties. First, it is nonnegative, with larger values indicating a higher degree of divergence. Two --- = Term A sums to 0 when the variances are equal, leaving contributions from the difference in means alone. Similarly, when the means are equal, term B equals 0, and any remaining divergence is attributed to difference in variances . Although age-at-death distributions are generally left-skewed, Edwards and Tuljapurkar suggested that Eq. remains a useful approximation. The KLD not only provides insight on educational disparities in mortality across the entire age-at-death distribution, but it can also shed light on the relative importance of each component-difference in means and difference in variances-to overall lifespan inequality. This decomposition is especially revealing when observed over time and can be suggestive of future mortality trends for various social groups as well as disparities between them. However, because the KLD does not indicate the direction of distributional divergence , trends in life expectancy and lifespan variation must be established beforehand. --- Results --- Educational Differences in Life Expectancy Life expectancy at age 25 by race, gender, and educational attainment is shown in Table 2. Overall, e 25 o increased by 1.5 years among non-Hispanic white women and by 3.2 years among white men between 1990 and 2010. Gains were higher among non-Hispanic blacks, amounting to 3.2 among women and 6.3 years among men. 8 Nevertheless, higher gains among blacks reflect a significantly lower starting point relative to whites of the same gender-a gap that was maintained, albeit diminished, over the 20-year period. Consistent with the gender gap in life expectancy, women fare better than men in each race group. Several notable patterns arise when broken down by educational attainment. First, educational disparities in life expectancy grew among all race and gender groups from 1990 to 2010. The difference in e 25 o between the most-educated and leasteducated white women grew from 2.5 to 9.3 years; a smaller increase was observed among black women, from 1.9 to 4.7 years. Educational differences in e 25 o are generally larger among men, and they too experienced widening disparities: from 6.1 to 11.9 years among whites, and from 6.9 to 8.6 years among blacks. Even though 8 Hereafter, non-Hispanic white and non-Hispanic black are referred to as simply white and black, respectively. ð3Þ educational disparities in mortality are still wider among men, women are slowly catching up. Second, absolute declines in e 25 o were observed among the least-educated white men and women, but not among blacks. Within two decades, e 25 o declined by 3.1 years among white women and by 0.6 years among white men with fewer than 12 years of schooling. At the same time, all other groups experienced gains in life expectancy. Life expectancy among the least-educated black men and women increased by 5.9 and 1.9 years, respectively. Overall, in each race-gender group, the highest gains were experienced by those with 13-15 or 16+ years of education, whereas only modest gains occurred among those with 12 years of education . These patterns are generally consistent with those reported by Olshansky and colleagues . However, using the current methodology, the declining trend in life expectancy is significantly attenuated for white women and disappears almost completely for white men. On the whole, the findings suggest that total gains in life expectancy are primarily driven by highly educated Americans, whereas the high school-educated lag behind and the low-educated-at least among whites-are increasingly worse off. --- Educational Differences in Lifespan Variation Patterns and trends in life expectancy by educational attainment are revealing, but they do not tell the whole story. Additional insights can be gleaned by exploring educational differences in lifespan variation. Trends in the standard deviation of age at death, conditional on survival to age 25, are summarized in Table 3. Overall, race-gender patterns mimic those of life expectancy in reverse. Higher variation is characteristic of men compared with women and blacks compared with whites. Between 1990 and 2010, S 25 among white women plateaued around 13.2 years and increased only slightly among white men, from 14.1 to 14.5 years. The opposite was recorded among blacks-S 25 declined from 16.4 to 15.5 years for men and from 15.7 to 14.8 years for women-suggesting that blacks, as a group, are becoming increasingly homogeneous with respect to age at death but are nevertheless disadvantaged compared with whites of the same gender. As with life expectancy, disaggregating trends in S 25 by educational attainment reveals significant disparities. Across the board, those with higher levels of educational attainment benefit from lower lifespan variation. This finding suggests that the highly educated are not only advantaged with respect to the expected age at death, but also benefit from lower dispersion or less uncertainty around that central indicator. In 2010, differences in S 25 between the least-and most-educated amounted to more than four years among men and about five years among women, regardless of race. In other words, although educational differences in life expectancy are greater among men, differences in variation are greater among women. Even more telling is the fact that within each race group, low-educated men and women have converged to similar values of S 25 , suggesting that they are now more similar to one another than are their highly educated counterparts. For some groups, S 25 has seen little to no change over time. For others, S 25 changed dramatically over the two-decade period. The least- and most-educated black men each experienced a decline of 0.8 and 1.1 years, respectively, suggesting lower dispersion around e 25 o . On the other hand, several groups experienced a significant increase in variation-almost all of which occurred among the low-and high school-educated. In particular, S 25 increased by 1.4 to 1.5 years among low-educated white women and among high schooleducated whites of both genders. The fact that lifespan variation increased mostly among the high school-educated is disconcerting and counters conventional wisdom based on trends in life expectancy alone . Only by observing differences and trends in lifespan variation do we notice diverging trajectories for the two groups. Interestingly, aside from black men who were severely disadvantaged at baseline, the college-educated did not exhibit significant declines in S 25 , which is consistent with a shifting mortality scenario rather than further compression. At the same time, the persistence of racial differences in lifespan variation even among the highly educated suggests that further improvements are in fact clearly possible, at least among blacks. Documenting changes in lifespan variation complements the picture painted by trends in life expectancy. However, an important question remains: what is the relative importance of each component to overall lifespan inequality? Decomposing the Kullback-Leibler divergence provides an approximate answer. --- Convergence and Divergence in Age-at-Death Distributions The KLD is a unitless quantity and, hence, not as easily interpretable as e 25 o and S 25 . Nevertheless, it exhibits two important advantages. First, the KLD allows a complete comparison between age-at-death distributions and is not limited to a single dimension of inequality, such as differences in life expectancy. Observed over time, it indicates patterns of convergence or divergence in age-at-death distributions between various subpopulations and can shed light on possible future scenarios. Second, it decomposes into two additive terms reflecting the relative importance of differences in means and differences in variances in explaining overall lifespan inequality. Figures 2 and3 depict trends in KLD and its components for white and black women, respectively, by educational attainment. To facilitate comparison across different educational attainment groups, all use the same reference distribution: white women with 16+ years of education in 2010, which is the group with the highest life expectancy and lowest variance in age at death. As of 2010, this group represents the most favorable lifespan conditions for women of either race. Similarly, Figs. 4 and5 show equivalent trends among white and black men, using white men with 16+ years of education in 2010 as reference. Consistent with the patterns observed in e 25 o and S 25 , Fig. 2 shows that low-educated white women have continued to diverge from the reference distribution, representing the most favorable gender-specific lifespan conditions, throughout the 1990s and 2000s. During this period, differences in both life expectancy and lifespan variation have contributed significantly to the overall disadvantage, and both components of inequality have been on the rise. Trends among the high school-educated are even more peculiar: whereas differences in life expectancy had declined from 1990 to 2010, differences in variation had increased . In fact, the latter were so pronounced that they now overshadow differences in life expectancy, resulting in net divergence from the reference distribution over time. In other words, lifespan variation is not only increasing in absolute terms, but has now become more important in explaining lifespan disparities between high school-and college-educated white women. Clearly, the shifting mortality scenario does not characterize all educational attainment groups, let alone the low-educated and even high school-educated. Finally, those with some college education appear to follow in the footsteps of the highly educated, which, by design, converge to the reference distribution in 2010. Figure 3 depicts the results for black women. Similar to whites, lifespan variation contributes more significantly to total divergence among lower education groups-as much as one-half in the case of women with 0-11 years of education. But unlike their white counterparts, all black women converged dramatically toward the reference distribution, primarily because of improvements in life expectancy. Lifespan variation, on the other hand, appears to have plateaued or decreased slightly among all but the high school-educated. Figures 4 and5 suggest that lifespan variation plays a smaller role in explaining overall disparities among men compared with women. In Fig. 4, all but the leasteducated white men have seen overall improvements in lifespan, with age-at-death distributions converging to that of college-educated men in 2010. Low-educated men, however, diverged from the reference distribution during the 1990s and plateaued during the 2000s. Although differences in means dominated over differences in variation in all educational attainment groups, the latter made a significant contribution to overall lifespan inequality among the low-and high school-educated. Rising lifespan variation among high school-educated men-as is the rise in its relative importancecounters the notion that they merely lag behind their college-educated counterparts, as one might conclude from trends in life expectancy alone. Instead, they are becoming increasingly diverse in their time of death and are more dissimilar to the college educated, who experienced continued improvements in life expectancy while lifespan variation remained steady at an all-time low. Educational disparities in the age-at-death distribution are significantly larger among black men than among white men. Nevertheless, all educational attainment groups appear to have made progress toward the reference distribution over time because of gains in life expectancy, with some decline in variation as well among the least-and most-educated. As with white men, lifespan variation contributes significantly to overall inequality among the loweducated albeit not as much as it does among women of either race group. In summary, trends in KLD suggest that almost all but the least-educated white men and women are converging to the age-at-death distribution of their white, collegeeducated counterparts. At the same time, a troubling pattern emerges. Although high school-educated Americans in all race-gender groups have seen gains in life expectancy, most have also seen increasing heterogeneity in age at death . Most importantly, lifespan variation is becoming an increasingly important component of lifespan inequality among the high school-educatedoften approaching and even surpassing contributions from differences in life expectancy. Focusing on mean-differences alone misses those trends and fosters a false set of suppositions about the future of mortality: namely, that high school-educated Americans, if not the least-educated, are simply lagging behind those with college education. Educational disparities in lifespan variation can therefore point to diverging scenarios in adult mortality. --- Discussion Educational disparities in U.S. adult mortality have been widening for several decades, with the college-educated faring better than any other educational attainment group . Most recently, declines in adult life expectancy have been observed among low-educated white Americans -results that are replicated and updated in the present study. Nevertheless, focusing on life expectancy-a central longevity indicator-overlooks other dimensions of lifespan inequality. Lifespan variation is a particularly revealing dimension of inequality, reflecting within-group heterogeneity in underlying population health as well as the uncertainty associated with an individual lifespan . Low-education groups consistently exhibit higher lifespan variation than highly educated groups, regardless of how variation is measured, both in the United States and in Europe . However, no study has yet to document change in lifespan variation over time across educational attainment groups. In the United States in particular, previous studies were also limited to non-Hispanic whites or did not disaggregate by race and gender. Using U.S. vital statistics data from 1990 to 2010, this study reveals trends in adult life expectancy and lifespan variation by educational attainment for black and white men and women. Over the two-decade study period, the gap in life expectancy at age 25 between low-and college-educated whites nearly doubled for men and more than tripled for women, reaching 11.9 and 9.3 years, respectively, by 2010. Among blacks, the same gap amounted to 8.6 for men and 4.7 years for women. Furthermore, e 25 o declined among low-educated whites by 3.1 years for women and by 0.6 years for men-estimates that are dramatically smaller than those reported by Olshansky and colleagues but consistent with evidence from the National Health Interview Survey around the same period . Departures from the former reflect differences in education categorization and a newly developed imputation method to handle missing data in the vital registry. Disparities in lifespan variation complement those in adult life expectancy and are equally illuminating. Consistent with previous studies, there are large educational differences in S 25 , the standard deviation of age at death conditional on survival to age 25, estimated between 4.0 to 5.5 years across all race-gender groups. From a population perspective, larger variation among lower-education groups reflects the lack of material and nonmaterial resources needed to shape healthier social environments and lifestyles, and therefore a lower capacity to optimize health throughout the life course . Indeed, since the 1970s, low-educated Americans have faced declining real wages , rising poverty and unemployment rates , and worsening prospects in the marriage market -all of which are associated with greater risk of mortality . At the same time, the expansion of education throughout the twentieth century has rendered the low-educated an increasingly select group possibly on the basis of family social background, which similarly affects adult mortality . Regardless of the underlying mechanism, these individuals face greater uncertainty regarding their length of life , the consequences of which are crucial for understanding social and economic behavior throughout the life course yet remain understudied and undertheorized in population studies. Over time, changes in lifespan variation provide a glimpse into the future of U.S. mortality and reveal diverging trajectories for various social groups. Researchers have long debated which scenario best describes the future of mortality for low-mortality countries : adult mortality compression, whereby gains in life expectancy are accompanied by decreasing lifespan variation; or shifting mortality, whereby the age-at-death distribution is translated to older ages while retaining its shape. Yet, these scenarios have been considered only for the United States as a whole. In Fig. 6, the change in S 25 is plotted against the change in e 25 o for each race-gender-education group, revealing two distinct clusters. The first, in the bottom-right quadrant, consists of college-educated Americans of all race-gender groups and low-educated blacks, for whom e 25 o increased and S 25 decreased from 1990 to 2010. Groups in this cluster are generally experiencing mortality translation or, when the vertical component is especially large , mortality compression. The second cluster consists primarily of low-educated and high school-educated whites, for whom S 25 increased by about 1.5 years, accompanied by losses in e 25 o or modest gains at best . This scenario is consistent with increasing young-adult mortality but warrants additional research as to the underlying change in age-cause-specific mortality rates in those education groups. Across Europe, higher lifespan variation among the low-educated is largely explained by excess youngadult mortality , although less is known about trends over time. The same is likely true in the United States, where young-adult mortality is generally higher than in other high-income countries and educational disparities in premature death rates have recently widened . Nevertheless, the findings in this article must be interpreted within the broader context of race, gender, and class inequality in human lifespans. In the United States, gender and race differences in life expectancy have peaked in the late 1970s and early 1990s, respectively, and have since diminished . By contrast, educational disparities in life expectancy have increased dramatically over the same period. Borrowing Linton's classic typology, it appears that lifespans in the United States are increasingly shaped by achieved, rather than ascribed, status. Although the extent of class mobility in the United States , the substitution of socioeconomic status for race and gender as the primary determinant of longevity is a recent phenomenon. The same period overlaps with the advent of neoliberal policies , which have since been adopted around the world . Key questions for future research are whether such policies are tied to the changing locus of lifespan inequality and, if so, whether we should anticipate similar trends in other market economies. This is not to suggest that race and gender no longer matter for individual lifespans. Indeed, they intersect with educational attainment in several important ways. First, although educational differences in e 25 o are greater among men, differences in S 25 are greater among women . Second, educational differences in both e 25 o and S 25 are larger among whites than among blacks, regardless of gender, in spite of the fact that lifespan variability in general is higher among blacks in almost all causes of death . Third, with respect to race, it appears that education is the overriding factor at the lower end of the distribution-evident in the convergence of e 25 o and S 25 between low-educated whites and blacks . By contrast, returns to higher education are larger for whites than for blacks, whose lifespans are shorter, on average, and more variable at the college level. Fourth, it appears that college education minimizes the gender gap in e 25 o but not in S 25 , which is in fact smaller among the low-educated. Perhaps further insight into these new findings can be gained by decomposing differences in lifespan variation by spread, allocation, and timing effects . The results in this study are illuminating, but some limitations should be noted. First, education reporting on death certificates in the National Vital Statistics System is inaccurate and, more generally, estimates derived from censusunlinked data tend to overestimate educational disparities in mortality . I attempted to minimize those potential biases by carefully imputing missing data and classifying educational attainment as consistently as possible over time. The assumptions made in the process are conservative yet realistic so as not to inflate disparities-which are in fact smaller than previously reported -and weigh all available information from the vital registry and census data. Second, the Kullback-Leibler divergence is measured only approximately based on the normality assumption. An exact decomposition into contributions from mean, variance, and residual shape differences to overall lifespan inequality is possible , although not as straightforward, and can be sought in future studies. Third, trends in life expectancy and lifespan variation are based on period life tables. However, growing educational disparities in mortality during the study period have been driven by cohort effects , which are also more consistent with the individual experience of disadvantage from a life course perspective . Unfortunately, the data requirements for estimating long-term cohort mortality are overwhelming-especially by educational attainment. In spite of those limitations, a discussion of educational disparities in mortality should not be limited to differences in life expectancy alone. Overlooking disparities in lifespan variation may lead to the erroneous conclusion that high school-educated Americans are merely lagging behind their college-educated counterparts and will eventually catch up. In fact, high school-educated whites are becoming increasingly heterogeneous in their lifespans in spite of modest gains in adult life expectancy, a trend suggestive of rising young-adult mortality . Together with low-educated whites, these groups currently account for more than one-quarter of the U.S. population aged 25 and older9 -hardly a negligible group of "select" individuals-for whom the lifespan is becoming increasingly uncertain. For those on the other end of the distribution, it appears that educational attainment homogenizes not only the life course but also the time of death. --- Nipqr , and N ipqr is the population size in the respective state, race, gender, and age group. Trends in Life Expectancy and Lifespan Variation by Education

The educational gradient in life expectancy is well documented in the United States and in other low-mortality countries. Highly educated Americans, on average, live longer than their low-educated counterparts, who have recently seen declines in adult life expectancy. However, limiting the discussion on lifespan inequality to mean differences alone overlooks other dimensions of inequality and particularly disparities in lifespan variation. The latter represents a unique form of inequality, with higher variation translating into greater uncertainty in the time of death from an individual standpoint, and higher group heterogeneity from a population perspective. Using data from the National Vital Statistics System from 1990 to 2010, this is the first study to document trends in both life expectancy and S 25 -the standard deviation of age at death above 25-by educational attainment. Among low-educated whites, adult life expectancy declined by 3.1 years for women and by 0.6 years for men. At the same time, S 25 increased by about 1.5 years among high school-educated whites of both genders, becoming an increasingly important component of total lifespan inequality. By contrast, college-educated whites benefited from rising life expectancy and record low variation in age at death, consistent with the shifting mortality scenario. Among blacks, adult life expectancy increased, and S 25 plateaued or declined in nearly all educational attainment groups, although blacks generally lagged behind whites of the same gender on both measures. Documenting trends in lifespan variation can therefore improve our understanding of lifespan inequality and point to diverging trajectories in adult mortality across socioeconomic strata.

recorded sound in the 1870s, some manner of piracy has existed, whether it was counterfeit wax cylinders, out-ofprint 78s reproduced by jazz and opera collectors, bootleg LPs of live performances and studio outtakes, remixed samplings of recordings circulated on cassettes and CDs by aspiring hip-hop artists, or mp3s of new and old music alike shared on sites like Napster and Limewire. In the case of out-and-out counterfeiting within the United States, Europe, or other established markets, where unofficial recordings were passed off for the original releases by reproducing not only the sound content but also the original packaging, the deleterious effect on the record industry is apparent. But for other types of piracy, the true economic consequences are harder to discern. Many times, piracy simply "filled in the cracks between official supply and real demand" by satisfying consumers' interest in obscure, forgotten, or emerging music that did not offer the financial rewards expected by the industry. The logic of supply and demand, however, did not compel the record industry to change its practices and try to reach underserved audiences. Instead, it called for stricter laws and stiffer penalties over the course of the twentieth century to tamp down unauthorized reproduction of any sort and to confine consumers as much as possible to popular music that brought the greatest returns on investment. While no business is begrudged for pursuing profits, the expanded protections the record industry sought often ran counter to the foundational liberties of U.S. copyright law, designed not only to reward the work of artists and craftspeople but also to encourage subsequent creative expression by others. For much of the century, legislators and courts resisted applying copyright protection to sound recordings, which, for a variety of reasons, did not come under federal law until the Sound Recording Act of 1972. Though certainly a milestone in the record industry's efforts to quash piracy, Cummings notes that this new law was a harbinger of more changes to come, and it "marked a turning point in American thought about culture, technology, and property" of all types. As the Copyright Act of 1976 and subsequent laws and rulings would later reflect, "the new way of thinking emphasized protection of capital outlays…rather than incentives [for artists to create new works]. By reinterpreting copyright in this way, Congress showed a willingness to view whatever was good for business as being good for copyright and the public in general" . This is one of many strong, compelling points conveyed in the book, characterizing not only how copyright was remade during the twentieth century but also how large media companies have gained the upper hand. Though ultimately the record industry lobbied successfully for changes in the law to protect its interests, Cummings observes a growing uneasiness about the current state of copyright, noting "a diverse movement among scholars and activists [that has] emerged to counter the perceived excesses of intellectual property law in the twenty-first century" . With Democracy of Sound, Cummings joins that movement, expanding and reframing ideas put forth in other notable recent books that grapple with the past, present, and future of technology, copyright, and personal liberty, such as Lewis Hyde's Common as Air: Revolution, Art, and Ownership and Siva Vaidhyanathan's The Googlization of Everything , along with serious appraisals of the record industry, like Steve Knopper's Appetite for Self-Destruction: The Spectacular Crash of the Record Industry in the Digital Age . "Uncritical support for intellectual property rights places private interests high above those of the public" , Cummings concludes, and Democracy of Sound is an important resource to inform further such critique. For that reason, this book should be part of every library collection, and it is essential reading for all librarians, who will benefit from the historical lessons and be reminded of the fundamental freedoms our work relies on and must strive to uphold.-D.J. Hoek, Northwestern University. --- Tomas A. Lipinski. The Librarian's Legal Companion for Licensing Information Resources and Services. Chicago: Neal-Schuman, 2013. 734p. paper, $130.00 . LCCN: 2012-18173. The Librarian's Legal Companion for Licensing Information Resources and Services will prove to be "the Bible" for librariansparticularly academic librarians-who seek to learn, and navigate, the intricacies of licensing agreements. As Professor at the School of Library and Information Science, Indiana University-Purdue University, Indianapolis, author Tomas A. Lipinski, JD, LLM, PhD, is well positioned to present the legal issues of licensing in a manner narrowly tailored to his principal audience, librarians and library administrators. His research is comprehensive and impressive, particularly when he cites case law and legal literature as evidence. Best of all, this handbook is useful to readers with multiple levels of experience with licensure-from the novice to the expert, rendering it an invaluable reference tool. In the Preface, Lipinski clearly articulates his authorial intent. He states, "My reason for writing The Librarian's Legal Companion for Licensing Information Resources and Services is simple: to allow you to read and understand the law surrounding the contracting of information content and, to a lesser extent, information services in library and related settings." He emphasizes the role of contract law as foundation for all discussion of licensing. He emphasizes the role of contract law, explores the "intersection of licensing and copyright" , and discusses more

The unauthorized reproduction of sound recordings today is generally discussed only in terms of the Internet and the unprecedented ease by which digital files can be copied and transferred. In Democracy of Sound: Music Piracy and the Remaking of American Copyright in the Twentieth Century, Alex Sayf Cummings shows that the filesharing activities and concerns of recent decades are just the latest chapter in more than a century of technological, legal, and social change. Shaping this history is the persistent tension between consumerswho find enjoyment, entertainment, and identity through music-and the composers, performers, and (to the greatest degree) corporations that own the associated copyrights and seek to maximize profit by controlling the availability and use of their products. Also part of this equation are pirates, those individuals and organizations that reproduce and distribute recordings in violation of the law, clearly disrupting the authority of copyright holders, as well as diminishing their profits in some cases. As Cummings demonstrates, though, the motivations and effects of music pirates are as diverse as the wide range of music being pirated, and, as legal restrictions and penalties have become increasingly severe, a valuable aspect of creative culture is being lost. Cummings is certainly critical of the record industry, but his purpose is not to support or justify piracy. Rather, he sets out to understand piracy-its origins, its functions, its costs, its benefits-and the reactions to it. In doing so, he presents the most nuanced, balanced, and complete assessment of unauthorized music copying yet published. Since the advent of

INTRODUCTION Migration is a growing phenomenon affecting European countries, which could be attributed to a combination of factors including war, political disturbances, socioeconomic hardships and sanctions 1 . Although throughout history migration has yielded diversity, cultural richness and socioeconomic development for communities, particularly in populations such as those in some European countries with alarmingly low fertility rates, ageing population and reduced workforce, it is not without its challenges. Migration inherently exposes vulnerability which can be amplified if pregnancy is also added into the complexities 2 . Depending on the country of origin, poorer pregnancy and birth outcomes amongst migrant women have been reported. These are generally summarised as a greater likelihood of interventional birth, low birthweight, small-for-gestationalage or premature birth, and a greater risk of perinatal mental health problems 3 . A considerable proportion of migrants are women of childbearing age 3 . It is therefore of paramount importance to provide appropriate perinatal services that are equitable and sensitive to the needs of a diverse range of communities. Here we present a multicentre European project called Operational Refugee And Migrant Mothers Approach . The ORAMMA research project was designed to develop and test the implementation of a high-quality maternity care model involving maternity peer supporters to enhance the care of migrant mothers and babies who have recently arrived in European countries. Here, we provide a summary of this project and also discuss a chain METHODS ORAMMA was a three-site multidisciplinary collaborative research project, involving several overlapping phases: 1) Exploring the evidence about migrant women's needs, their experiences of maternity care and current guidelines relevant to their care to develop a best-practice model of care 4 , with the findings used to inform the development of training materials for both healthcare professionals 5 and MPSs 6 ; 2) Undertaking community engagement and recruiting maternity peer supporters ; and 3) Implementing this model of care for migrant women during pregnancy, birth and the postpartum period in three European settings. Ethical approval for the ORAMMA project was obtained . Further details on the ORAMMA project are available elsewhere 7 . --- RESULTS --- Exploring the evidence The systematic review of migrant women's experiences found that some women had difficulty accessing care as they were unaware of their entitlement to care, were unfamiliar with the maternity care system in the new country, and faced practical barriers such as communication challenges, lack of cultural understanding amongst healthcare professionals as well as transportation and financial barriers. This also showed that continuity of care, being listened to, not being stereotyped and developing a trusting relationship between professionals and mothers were important 8 . --- Community engagement and incorporating MPSs in maternity care The ORAMMA project adopted a community engagement approach that capitalised on the experiences of migrant women who had been living in the host country for a longer period of time or who were second generation migrants. Within the UK, 25 women were recruited from ethnic minority communities and undertook training to become MPSs, with 17 MPS matched to one or more newly arrived migrants to support them through pregnancy, birth and the early postnatal period; promoting cultural understanding and communication with healthcare professionals; providing social and emotional support; and enabling childbearing migrant women to navigate the unfamiliar healthcare system. The women who volunteered to become an MPS were motivated by their own experiences of being newly arrived migrants in the past or a sense of altruism. Table 1 gives some illustrative quotations from MPSs and pregnant migrant women. There was a range of benefits of this model of peer support for newly arrived childbearing migrant women. As well as support to access maternity care and overcome language barriers, MPSs advocated for them in their encounters with healthcare professionals when the woman desired it. MPSs provided emotional support and increased the women's confidence, helping them overcome loneliness, encouraging them to build relationships with others and promoting bonding with the new baby. The MPSs were a valued source of information in a new place, and the women appreciated the practical support they received from their MPS who helped them address a range of issues and needs including: housing, arranging bill payments, benefit applications, and acquiring equipment and clothing for the new baby. The MPSs found that being involved in the project gave them a sense of personal satisfaction, feeling valued and boosting their self-esteem. They appreciated the opportunity to have a new experience and challenge, gain new knowledge and skills, and make a difference to newly arrived migrant women in the community. --- Moving beyond the project to create positive local community impact The ORAMMA project was completed in March 2019, however, the MPSs were enthusiastic and motivated to develop further their community-based initiatives to support recently arrived migrant women. Links with local Refugee Council project workers allowed the research team to share lessons learnt from the ORAMMA project and has led to the involvement of ORAMMA MPSs in an emerging project 'Health Access for Refugees Programme' . ORAMMA MPSs have had the opportunity to share their ORAMMA training and experience with other HARP volunteers and offered peer support to recently arrived migrant women in the local area within weekly community-based antenatal and postnatal groups. The MPSs have participated in further opportunities across the city for volunteering roles within a Policy case studies number of community groups who support asylum seekers, refugees and vulnerable migrants in accessing health and maternity services such as 'Pregnancy Birth and Beyond', 'Breastfeeding Peer Support', and 'Empowering Parents, Empowering Communities '. They have also been working with Forging Families and LIGHT who have reached out to the MPSs due to limited availability of volunteer peer supporters from ethnic minority backgrounds in their organisations. They viewed this as an excellent opportunity to expand their services and capitalise on the skills, training and helping attitude of these volunteers to support mothers from diverse communities and those from migrant backgrounds. The support has been recognised as a pathway to aid the transition back to community services after receiving specialised perinatal mental health input. The group has evolved to a volunteer group called 'Friendly Mothers' who share information about lifestyle and reproductive health matters , suggesting evidence of adaptation, growth and sustainability. The group's adaptive capacity has been demonstrated during the COVID-19 pandemic by the setting up of its own WhatsApp facility to aid communication and sharing of knowledge amongst members. The social capital impacts can be seen in the bonding qualities of the relationships, and mutual support established between MPSs and migrant mothers, with the expressed sense of reduced isolation and loneliness whilst being empowered to articulate their needs and pregnancy health concerns. MPSs' narratives demonstrate personal benefits in terms of skill development, boosts to self-esteem, career-building and satisfaction from having helped vulnerable women at a critical period in their lives. The continued impact has been captured in a recent Migrant Matters Festival -broadcasted 'virtually' due to COVID-19 pandemic 9 . The ORAMMA MPS training materials have been adapted to enhance both the recruitment of peer supporters from ethnic minority groups, also making the training more relevant and culturally sensitive. Furthermore, the training package for healthcare professionals in culturally sensitive care has been delivered in continued professional development sessions to further train General Practitioners within the locality. The training resources also continue to be developed for further online distribution among midwives and other healthcare professionals. --- DISCUSSION Our project resulted in training packages as well as establishing a group of MPSs from migrant/ethnic minority background, which continued their impact after the life of the project supporting migrant pregnant mothers as well as supporting each other. This is particularly important since there currently appears to be a shortage of volunteers from ethnic or migrant backgrounds within both professional and non-medical support roles such as peer supporters 10 . Discussions have been taking place to offer help from ORAMMA project findings/products, particularly the involvement of MPSs in various initiatives with multiple benefits of community engagement, facilitating support to vulnerable mothers/women from marginalised backgrounds as well as further development opportunities for the MPSs and volunteers. The support systems using digital platforms already established by MPS have enabled continuing the sharing of information and knowledge around keeping healthy and safe, despite restrictions during the COVID-19 pandemic. The engagement of MPSs in supporting newly arrived mothers has multiple advantages of addressing social isolation and marginalisation of migrant communities at several levels, with potential benefits of improving access and enhancing health illiteracy and health outcomes amongst recently arrived migrant women. Benefits were also noted for MPSs including reduced sense of isolation and increased self-esteem and community engagement. --- CONFLICTS OF INTEREST The authors have each completed and submitted an ICMJE form for disclosure of potential conflicts of interest. The authors declare that they have no competing interests, financial or otherwise, related to the current work. V. G. Vivilaki and H. Soltani report grants from Consumers, Health, Agriculture and Food Executive Agency, during the conduct of the original ORAMMA study. V. G. Vivilaki also reports that she is the Editor-in-chief of the EJM journal. --- FUNDING The original ORAMMA project was funded by the Consumers, Health, Agriculture and Food Executive Agency, with Project number 738148. No direct funding was received for the continued community engagement work. --- PROVENANCE AND PEER REVIEW Not commissioned; externally peer reviewed.

INTRODUCTION Migration is a growing phenomenon affecting many European countries, with many migrants being of childbearing age. Depending on the country of origin, poorer pregnancy and birth outcomes amongst migrant women have been reported. Providing appropriate culturally sensitive perinatal services is of paramount importance. METHODS The Operational Refugee And Migrant Mothers Approach (ORAMMA) was a three-site multidisciplinary collaborative research project, designed to develop and test implementation of a high-quality maternity care model including peer supporters for migrant women who have recently arrived in European countries. Community-based activities were undertaken to ensure ongoing local impact for maintaining supportive interactions amongst peer supporters and recently arrived migrant women in the UK. RESULTS The women who volunteered to become maternity peer supporters were motivated by their own experiences of being newly arrived migrants in the past or a sense of altruism. Forging links with multiple local community groups enabled the continuation of the support provided by maternity peer supporters, including during the COVID-19 pandemic. CONCLUSIONS Engagement of maternity peer supporters in supporting newly arrived mothers has multiple advantages of addressing social isolation and marginalisation of migrant communities, with potential benefits of improving access and enhancing health literacy and health outcomes amongst recently arrived migrant women as well as creating a self-supporting network for peer supporters themselves.

INTRODUCTION In March 2020, the World Health Organization declared the disease caused by SARS-CoV-2 coronavirus a "pandemic." To reduce the risk of contamination, many countries have ordered a strict lockdown characterized by social distancing and restrictive isolation measures. In Belgium, such strict restrictions were in place from March 18th to June 8th 2020 . All restaurants and shops were closed down. People were instructed to keep at least 1.5 m distance between each other and anyone who did not perform "essential work" was instructed to work at home . If working from home was not possible, people became temporarily unemployed. As a result of these governmental lockdown measures and the COVID-19 pandemic, most people's work and social lives were restricted and people were confined to their homes and to the people with whom they lived. This pandemic has profoundly affected people's and couples' daily lives and created multiple daily challenges. One important challenge has been maintaining well-functioning intimate relationships. Research on couple relationships showed that external stressors can threaten the quality and stability of couples' relationships . Yet couple satisfaction and relationship can directly and indirectly influence each partner's physical and mental wellbeing . So, the influence of the lockdown on the couple relationship seems to be of great importance for social and health policies and needs to be examined. More and more studies have investigated the quality of couple relationship associated with the spread of COVID-19 and conflicting results appeared, as illustrated in Candel and Jitaru . Most of them were cross-sectional and assumed that the pandemic might constitute a threat to couples' relationship quality, at least in the short-term . COVID-19 pandemic and lockdown would lead to a decrease in relationship satisfaction with greater couples' conflicts and difficulties, irrespective of whether or not participants experienced changes in their employment situation during the COVID-19 , a decrease in sexual satisfaction, especially sexual enjoyment and the frequency of intimate and sexual behaviors , and a higher prevalence of physical and psychological violence . Schokkenbroek et al. indicated that women especially experienced more relational stress during the lockdown than in normative situations. On the other hand, Günther-Bel et al. found that partners reported high levels of couple adjustment and cohesion during the pandemic because of a sustained proximity, the absence of third-party involvements , and more time for shared couple activities. Williamson showed that couple satisfaction remained stable during the first weeks of the pandemic and that people blamed their partners less, preferring not to attribute their negative behaviors to their internal characteristics but rather to the stressful pandemicrelated context. The high salience of the pandemic as a stressor likely increased people's ability to see it as a potential driver for their partner's behaviors, compared with smaller daily stressors that are often overlooked as a source of partners' behavior . These previous studies highlighted important psychological mechanisms of couple life that could be affected by the COVID-19 pandemic and lockdown and would explain a decrease in couple satisfaction. First, based on the vulnerability-stressadaptation model , Pietromonaco and Overall suggested that facing COVID-19-related external stress is likely to increase harmful dyadic processes , which would undermine couples' satisfaction. As such, negative emotions and relational turbulence increased from before the pandemic to during the pandemic due to an increase in spousal interference . Second, the lockdown leads to a decrease of external support for couples. Yet all couples need external support to grow together and cope with the challenges of life. As such, social networks could have a facilitative role on couple stability. For example, favorable reactions from significant others are likely to strengthen the bonds of a couple. Relatives may also help stabilize a close relationship by providing support and encouragement to those couples who are experiencing difficulties . Third, the COVID-19 pandemic and lockdown led to restricted opportunities to enjoy leisure time activities outside the household and to the obligation to spend more time at home . This could lead to a decrease in individual general life satisfaction that might spill over into couple relationships. Fourth, additional challenges are observed when one of the partners has a chronic disease, which leads to lower psychological wellbeing and more fears and worries about the spread of the COVID-19 within the couple . The illness of a family member was associated with increased fear of COVID-19, anxiety, depression, and stress, which affected the relational quality of couples . On the positive side, the lockdown led romantic partners to spend more time together due to isolation measures and working conditions. Vagni and Widmer showed that the more time couples spend together, the more likely they are to experience high partnership quality and to report being satisfied with their relationships. Thus, spending more time with one's partner could positively influence couple functioning and satisfaction during the lockdown. Second, the COVID-19 pandemic might constitute a stress for couples' partners, which could activate couple partners' stress management processes. According to Bodenmann's Systemic-Transactional Model of Dyadic Coping , when partners deal with a stressor affecting them both directly and simultaneously, such as in the COVID-19 pandemic, the source of stress is defined as common, and dyadic stress is observed. To cope against dyadic stress, partners can initiate a dyadic coping process, which is the interplay between both partners' stress and coping reactions as well as proper common responses to the dyadic stressor. Self-reported dyadic coping was associated with higher levels of relationship satisfaction , decreased verbal aggression during times of stress , and lower levels of divorce and separation among married couples . Dyadic coping has already been studied as a buffering factor contributing to couples' relationship quality during the COVID-19 stress-related pandemic, with a direct effect or a moderating or mediating role on couple's relational outcomes. In this regard, Bar-Kalifa et al. observed that positive dyadic coping had a direct effect on relational outcomes, such as perceived partner responsiveness . Randall et al. showed that perceived supportive dyadic coping provided by the partner moderated the negative association between post-COVID-19 distress and couples' relationship quality. Donato et al. reported that concerns about the COVID-19 situation significantly threatened individuals' psychological wellbeing. They also demonstrated that these concerns positively predicted explicit stress communication, which in turn positively predicted perceived supportive dyadic coping provided by the partner, which finally positively predicted psychological wellbeing. These previous studies indicated that dyadic coping would be a good candidate to buffer partners from couple and individual distress during the pandemic. --- PRESENT STUDY While interesting, previous studies on couple satisfaction during the COVID-19 pandemic and lockdown focused on a crosssectional individual perspective, without considering the dyadic trajectory of couple satisfaction during the lockdown. The current study was a 4-waves longitudinal study starting at the beginning of the lockdown in Belgium and ending at a final stage of unlockdown with the objective to examine the evolution of couple satisfaction with a dyadic perspective. Our research questions were the following: What was the longitudinal influence of the lockdown on couple satisfaction? Did partners perceive a positive or a negative influence of the lockdown on their relationship? Did the lockdown influence both partners in a similar or different way? --- Hypothesis 1: The Intraindividual Trajectory of Couple Satisfaction During the Lockdown Previous research highlighted more costs than benefits . Consequently, we hypothesized that the COVID-19 pandemic and lockdown would progressively lead to lower levels of intraindividual couple satisfaction. --- Hypotheses 2: Time-Invariant Predictors of Couple Satisfaction Trajectory During the Lockdown The second aim was to consider variables for explaining interindividual differences in couple satisfaction trajectory . Previous research has shown significant decreases in relationship satisfaction over time. Partners who have been together longer tend to experience lower couple satisfaction . Consequently, we hypothesized that the longer the partners have been together, the more the lockdown negatively influences them. Next, the lockdown led partners to stay at home, to decrease their personal leisure activities and to work at home, that is, to spend more time together. Previous studies indicated a positive association between the partnership quality and the amount of time partners spend together. We hypothesized that the more time couples spent together, the more couple satisfaction increased during the lockdown. The third variable concerned the presence or the absence of children at home during the lockdown. Twenge et al. showed that parents had significantly lower couple satisfaction than couples without children. Furthermore, Günther-Bel et al. reported high levels of dyadic adjustment during lockdown in partners without children, in comparison to parental partners. Consequently, we hypothesized that the presence of children at home would increase the burden related to the COVID-19 pandemic and lockdown, which would lead to lower levels of couple satisfaction over time. --- Hypothesis 3: The Dyadic Trajectory of Couple Satisfaction Over Time Previous studies on couple satisfaction during the lockdown focused on an intraindividual perspective, without considering the mutual influence between both partners. Yet, all couple or family members were forced to stay home together for several months. In this sense, the lockdown could be considered as an interdependent event, i.e., one partner's experiences may be related to the other partner's experiences . Previous research has already shown that each partner's relationship satisfaction and personal characteristics within couples were similarly affected by life events and changed in tandem. Consequently, we expected a positive association between one partner's couple satisfaction trajectory and that of the other partner within the same couple. An Actor-Partner Interdependence Model , a data analytic approach designed to deal with dyadic data and to consider statistical dependencies due to invariant and time-varying characteristics of the dyad members, was used to test these 3 hypotheses, namely the intraindividual trajectory of couple satisfaction during the lockdown, the influence of time-invariant predictors on couple satisfaction trajectory during the lockdown, and the positive association between both partners' couple satisfaction trajectory. To measure the trajectory of couple satisfaction, we used a couple satisfaction inventory. However, given that the intercept was at the beginning of the lockdown, we were unable to assess a before-after COVID-19 pandemic and lockdown. We could only evaluate the evolution of the couple satisfaction during the lockdown process. Consequently, we also added a measure relative to the partners' perceptions of the influence of the lockdown on the couple's and the family's relationships. As such, it allowed us to evaluate if partners had a positive or negative perception of the lockdown in relation to couple and family relationships and if this perception changed over time. --- MATERIALS AND METHODS --- Participants and Procedure Data were longitudinally collected from a sample of 108 couples. The participants' ages ranged from 18 to 74 years old . 55 couples were parents: 23.7% had a single child, 47.5% had two children, 24.6% had three children, and 4.2% had 4 children or more. The duration of the relationships was around 12 years . During the lockdown, the participants spent a large amount of their time with their partner . Participants were recruited via social networks . The questionnaires were completed online via Lime Survey 3.0 +. To participate, participants should be 18 years old minimum, be in a romantic relationship, and live with their partner. With regards to ethical approval, institutional review board approval was obtained from University of Mons . Four waves of data were collected in a longitudinal intensive research program during the lockdown in Belgium , i.e., Time 1 , Time 2 , Time 3 , and Time 4 . Sociodemographic information and information about the specific lockdown context are presented in Table 1. --- Measures --- Couple Satisfaction Couple satisfaction was assessed by means of a French version of the Marital Satisfaction Inventory Revised . This questionnaire consisted of 13 scales, i.e., Conventionalization, Global Distress, Affective Communication, Problem-solving Communication, Aggression, Time Together, Disagreement about Finances, Sexual Dissatisfaction, Role Orientation, Family History of Distress, Dissatisfaction with Children, and Conflict over Children Rearing. Because of the longitudinal design and the risk of high attrition, only four scales were used in the current study, i.e., Global Distress , Difficulties in Problem-solving Communication , Aggression , and Conflicts over Children Rearing . Only parents had to answer for Conflicts over Children Rearing. These four scales were used because of their relevance related to the contextual situation of the pandemic. A 5-point Likert-type scale was provided, with higher scores indicating greater relationship distress. The MSI-R has shown high Cronbach's alphas and hence was highly reliable with high construct, predictive, and convergent/discriminant validity and high temporal stability . In our sample, αs were around 0.70, 0.87, 0.92, and 0.96 for Aggression, Conflicts over Children Rearing, Difficulties in Problem-solving Communication, and Global Distress, respectively. --- Perceived Influence of the Lockdown on Couple and Family Relationships To assess the perceived influence of the lockdown on couple and family relationships, a short questionnaire was created. Participants were asked to answer 10 items relative to their positive and negative perception of the influence of the lockdown on their couple and family satisfaction . A 5-point Likert-type scale was provided, with higher scores indicating greater perceived positive influence of the lockdown on couple and family relationship. αs were higher than 0.78 and 0.88 for couple and family relationships, respectively. --- Analytical Strategy The main analyses were conducted using a multilevel modeling framework with the HLM 7.00 software . We used the Actor-Partner Interdependence Model , a data analytic approach designed to deal with dyadic data through repeated measures. A two-level hierarchical linear modeling was used: The level 2 data referred to couple variables while the level 1 data referred to all variables that did not include couple information. Couple satisfaction was treated as the outcome. Couple duration, the presence of children at home, and the number of hours spent together were treated as time-invariant predictors added in the Level 2 equation . The partner's couple satisfaction was introduced as a time-varying covariate in the model predicting the actor's couple satisfaction. Each time-varying covariate had two sources of variation; therefore, it was treated as two variables instead of one . These two sources of variation were likely to have differential effects on the outcome: a between-person effect and a within-person effect, respectively. The time-varying covariate was within-person centered in order to address bias due to unobserved heterogeneity or unmeasured factors that varied across individuals and had a consistent effect over time on the construct of interest . The between-person effect concerned the effect on couple satisfaction of stable individual differences between partners . To obtain the between-partner effect, the average level of each partner's couple satisfaction scores over the four assessment waves was calculated and added as a predictor. This procedure was used to examine the pure effect of change in the time-varying covariate over time . For the study, the time variable was expressed in the metric of weeks. The exact difference of time between waves for each participant was respected, making it possible to observe any changes in couple satisfaction between these four waves of measurement. --- RESULTS --- Missing Data There was attrition of 45.7% between T1 and T4. Because attrition is common in longitudinal studies, HLM estimates were based on all the available data with the assumption that the missing data were random . Statistical comparisons between participants who dropped out and participants who completed the four waves revealed no systematic significant differences between parents and nonparents --- Preliminary Analyses The means and standard deviations of the outcome variables and the Pearson correlation coefficients examining the stability of the repeated measures over time are presented in Table 2. The correlation coefficients were globally high across waves, except for Aggression whose coefficients were medium. The intercorrelations between Couple Satisfaction Variables at T1 and T4 are presented in Table 3: The correlation coefficients were low to moderate. --- Actor-Partner Interdependence Model Analyses Significant slope values indicated that all outcome variables changed during the lockdown . As such, Global Distress, Difficulties in Problem-Solving Communication, Aggression, and Conflicts over Children Rearing significantly decreased by 0.09, 0.13, 0.12, and 0.09 per week, respectively. While all coefficients were significant , Difficulties in Problem-Solving Communication and Aggression showed the higher coefficients. Both variables related to the perceived influence of the lockdown on couple and family increased by 0.28 and 0.26 per week, respectively, indicating that partners had the feeling of a more positive influence of the lockdown on couple and family over time. Table 4 also shows that the duration of the relationship, the number of hours spent together during the lockdown, and the presence or not of children at home were not predictors of couple satisfaction trajectory. While some coefficients were significant , their coefficients were low. Finally, Table 4 shows a positive association between couple satisfaction trajectory of the actor and his or her partner's couple satisfaction trajectory during the lockdown. For every unit of change in their partner's level per week, there was a positive change in the actor's Global Distress --- DISCUSSION The current study was a 4-waves longitudinal research, starting at the beginning of the lockdown, with the objective to examine the trajectory of couple satisfaction during the lockdown with a dyadic perspective. Positive Intraindividual Changes of Couple Satisfaction During the Lockdown Bowlby observed that family members stay in proximity for weeks after a disaster because the affiliation is comforting during a crisis. What about in the case of the COVID-19 pandemic, when family proximity was imposed and not chosen? Our results showed that the surveyed couples on average have adapted better and better to the new situation , especially with a decrease in difficulties in problem-solving resolution and aggression. How do we explain these positive changes in couple satisfaction during the lockdown? First, the vulnerability-stressadaptation model considers how external stress can affect relationship quality. Pietromonaco and Overall suggested that COVID-19 leads to higher levels of stress, which would undermine couples' satisfaction. The COVID-19 pandemic could also lead to a decrease in external stress for couples. As such, during the lockdown, couples coped less with social and family obligations, except for online appointments. Yet, Stein showed that family felt obligations were related to higher levels of psychological symptomatology, which could undermine partners' satisfaction. Felmlee also underlined the negative side of social networks, such as competition between friends and the dyadic partner. Such negative relational context could be highly negative for the couple's relationships. Reframing the vulnerability-stressadaptation model, the lockdown could lead to a decrease in some external stressors, that is, social and family obligations, which would be beneficial for couples' relationships. Second, as Günther-Bel et al. showed, partners shared more time together and would experience more sustained proximity during the lockdown. The increase in proximity between partners could increase their perception of warmth within the couple as well as the feeling of being more similar over time , which could have a positive impact on couple satisfaction. Third, the lockdown may have led the partners to share and to regulate more their personal emotions within the couple rather than with friends or large family. Thus, couple's sharing and regulation of emotions could initiate support and contribute to higher togetherness . Finally, Williamson indicated that the experience of the early weeks of the pandemic led partners to become more forgiving and less blaming of their partner's negative behaviors by attributing them less to their partner's internal characteristics and more to the stressful pandemicrelated context. The high salience of the pandemic as a stressor likely increased people's ability to see it as a potential driver for their partner's behaviors, compared with smaller daily stressors that are often overlooked as a source of partners' behavior . The coefficients of change were especially high for Difficulties in Problem-Solving Resolution and Aggression, which decreased over time. On one hand, partners had the feeling of becoming increasingly effective for resolving couples' conflicts during the lockdown. Spending more time together than usual allowed partners to have more couple discussions , which allowed the couple to better resolve the difficulties in their daily life . On the other hand, our results also showed a decrease in couple's aggression. These results were partially in contradiction with those of Jetelina et al. that indicated elevated levels of intimate violence during the lockdown. Our research did not study couple violence but couple aggression. For many couples, the ups and downs of daily life are connected such that stressors impacting one partner would also impact the other partner. However, the lockdown could have decreased the number of stressors of family life for both partners, which, in turn, could have decreased the risk of emotional contamination between them. Thus, less daily stress would reduce the risk of aggression and hostility within the couple. Our methodological design raised a question: Since the intercept of our longitudinal research was situated at the beginning of the lockdown, instead of just before the lockdown, could it be possible that couple satisfaction suddenly decreased at the beginning of the lockdown, because of its non-normative aspects and the resulting stress, and after, progressively increased until its initial level ? To bypass this issue, we measured if partners perceived that the lockdown was positive or negative for their couple and family. Our results showed that partners perceived the influence of the lockdown as more and more positive over time on couple and family functioning. This result underlined the capacity of resilience and coping skills of couples and families when facing the pandemic. Previous research has already demonstrated the system's resilience toward disaster like COVID-19 pandemic by processes such as meaning-making of adversity and fostering a positive look. Thus, considering our results, we could hypothesize that the partners focused their attention on positive characteristics of the lockdown , rather than on negative ones . --- Time-Invariant Predictors of Couple Satisfaction Change During the Lockdown Three time-invariant predictors were included in the model to explain couple satisfaction trajectory during the lockdown: the duration of the couple relationship, the time spent together during the lockdown, and the presence of children at home. None of these three contextual variables constituted risk or buffer factors for couple satisfaction during the lockdown. First, the Erosion Theory of relationship satisfaction over time underlined that couple satisfaction tends to slowly decline over time, especially for parental couples. Differences in couple satisfaction related to the duration of the relationship and/or the presence of children at home were observed at the intercept but not at the slope related to the strict period of the lockdown. As such, the duration of the relationship and the presence of children were not predictors of couple satisfaction trajectory in the early stage of a time-limited lockdown. Second, the time spent together during the lockdown was not a predictor of couple satisfaction trajectory. Our descriptive statistics showed that partners tended to spend a great amount of time together , with small standard deviations. Consequently, it led to no differences in the slope value. --- Within-Person and Between-Person Effects in Couple Satisfaction During the Lockdown Partners' couple satisfaction changed in tandem during the lockdown. The perception of the couple relationship tended to evolve similarly between partners. Despite the lockdown and related stressors, the partners tended to share the same perception of their couple and to develop similarly. The lockdown led partners to experience similar changes in couple satisfaction and to follow the same dyadic trajectory over the lockdown. Because partners were forced to stay home together for several months, the lockdown could be considered as an interdependent event . Our results were like those of previous research which has shown that each partner's relationship satisfaction as well as personal characteristics within the couple were similarly affected by life events and changed in tandem. Now, our results also showed a negative association between couple satisfaction of the actor and his or her partner's couple satisfaction introduced as a between-person variable. This means that both partners can differently, on average, assess their level of couple satisfaction. Even if both partners have different levels of couple satisfaction, they experienced similar changes in couple satisfaction and developed in the same direction. Consequently, the lockdown would be a dyadic phenomenon more than a phenomenon that exacerbates the partners' differences and perceptions. --- GENERAL CONCLUSION, RESEARCH AND PRACTICAL HIGHLIGHTS, AND LIMITATIONS The current study was the first one to investigate the longitudinal influence of the lockdown on couple satisfaction and showed that both partners had the same longitudinal trajectory. Although the lockdown had a negative influence on individual mental health , our results also showed that the surveyed couples on average have adapted better and better to the new situation , especially in terms of better resolution of conflicts and less use of aggression within the couple. Some lessons could be learned from this lockdown experience. The first lesson pertains to the notion of time spent in the couple and family. The lockdown was a temporary intensive experience during which all members of a family or couple continuously live together in their house, maintaining their usual activities without being on holidays. Our results showed that this has been relatively positive for the couple relationship. Thus, the couple needs time to cope with daily couple problems. The lockdown allows skipping the social, relational, and extra-family obligations that could sometimes be a stressor for the couple. More family and couple time would be a protective factor against aggression and difficulties in resolving problems within the couple. The second lesson refers to the dyadic trajectory of couple satisfaction. The lockdown allows one to intensively share one's partner's daily life and to experience the same perception of couple satisfaction. Hence, sharing the same perception of the couple relationship is also a protective factor for couples, facilitating coordination and providing confidence about the predictability of partners' attitudes and behaviors . The first limitation of the study was related to the sample size. As all longitudinal designs, our study suffers from attrition. The questionnaire included many items, which may have discouraged some participants. Second, when all social interactions are restricted to nuclear family and the couple, it can lead to cognitive dissonance . As such, there could be a discrepancy between each partner's social behavior and the standard to which it is compared. The tension resulting from this discrepancy could lead partners to change one of the dissonant elements, either their social behavior , or by changing their cognition . The resolution of the cognitive dissonance could perhaps explain our optimistic results. Third, the current study corresponds to a strict lockdown in Belgium. Since then, there were two semi-lockdowns . Thus, the lockdown during Spring 2020 could have been a positive experience for couples and families because it was the first one, time-limited, and with nice weather. It was perhaps experienced as a "honey-moon." However, how did couples and families experience the following lockdowns? These were less time-limited and without nice weather . It could be interesting to compare the experiences of both the first and the subsequent lockdowns. Fourth, our descriptive results showed that the participants at T1 were on average satisfied with their relationship. Consequently, our results should be considered with caution because of a potential bias of selection, which may indicate that the couples who adapted better and better to the lockdown would also be ones who were initially satisfied with their relationship. Finally, the intercept of our longitudinal study was the beginning of the lockdown. We could not compare pre-lockdown and postlockdown periods. To cope with this methodological problem, we included items for measuring perceptions of the influence of the lockdown on couple and family relationships. Future research should compare the first and subsequent experiences in lockdown by including predictors of the intraindividual and dyadic couple developmental trajectory such as a depression, anxiety, and stress scale , a dyadic coping scale or a cognitive dissonance measure . --- DATA AVAILABILITY STATEMENT The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. --- ETHICS STATEMENT The studies involving human participants were reviewed and approved by the Ethical Committee, Faculty of Psychology, University of Mons. The participants provided their written informed consent to participate in this study. --- --- Conflict of Interest: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Publisher's Note: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

In March 2020, the World Health Organization declared the disease caused by SARS-CoV-2 coronavirus "pandemic." To reduce the risk of contamination, many countries have ordered a lockdown characterized by social distancing and restrictive isolation measures. While the lockdown has proven to be quite effective in terms of physical health, little is known about its impact on couple satisfaction in a dyadic perspective. The current research was a 4-waves longitudinal study (i.e., from March to July 2020) with the objective to examine the trajectory of couple satisfaction during the lockdown with a dyadic perspective (N = 108 couples), including the presence (or absence) of children at home, the number of hours spent together, and the duration of the relationship as time-invariant predictors and the partner's couple satisfaction trajectory as a time-varying covariate. Results showed positive intraindividual changes in couple satisfaction during the lockdown, especially an increase in partners' effectiveness for resolving couple conflicts and a decrease in partners' aggressiveness. Partners had also perceived the influence of the lockdown as more and more positive over time on couple and family functioning. Finally, the couple satisfaction of both partners changed in tandem during the lockdown: The perception of the couple relationship seems to similarly evolve between partners.

Introduction The question of the impact of the family environment and its functionality on the general quality of life for pre-adolescents and adolescents remain an issue of both scientific and clinical relevance . The family, as a unit of care has a great effect in tackling adolescent problems and well-being , its functionality should be more often considered as a determinant for their quality of life . There is a consensus in the systemic family therapies approach that functionality of the family is relevant for how teenagers feel, both physically and mentally . Most important, perceived interpersonal emotional bonding within the family can clinically affect them . Thus, the present study argues and supports this line of studies due to its relevance in both theory and practice. Like adults, pre-adolescents and adolescents can perceive discrepancies between the real and ideal family reality they are in from early developmental stages and according to theories, a higher gap between the two levels usually results in emotional distress . As studies show, adolescent`s general health and mental status are affected when they gain the capacity to reflect on their self-states and possess self-discrepancies . Although there are studies that support the fact that perceiving selfdiscrepancies is present for pre-adolescents and adolescents, there are no studies that explicitly explore the perceived discrepancies regarding one's family functionality. Thus, the main goal of the research is to explore how perceived discrepancies or high similarity between the real perceived family functionality and the ideal desired family functionality would influence the physical and mental quality of life of adolescents. --- Exploring Perceived Discrepancies regarding Family Functionality and its Effects over Quality of Life The family functionality concept has always been considered either a risk or protective factor for the development of children and the behavior of adolescents and in an extended manner for their quality of life . Also, we know that poor family functioning is correlated with the course of serious mental disorders in youth and adolescents . Quality of life is a generous concept within the literature and in an extended and simplistic way, it refers to the satisfaction that one has when he reflects on multiple but general areas of life . Still, the most relevant factors that seem to have a greater impact over quality of life are family functioning, one's worldview and daily experience . According to Rutter , parental caring during the infant period is very healthy and protective, but in contrast, such parental behavior may hinder healthy development during adolescence. One model that has great both theoretical and practical implications for one's Tofan quality of life is the circumplex family model regarding family functionality. Family functioning is defined as the way in which the family members interact, react to, and treat other family members . The model describes several types of families from healthy to unhealthy and also its effect on how members would feel and react . The interplay between emotional bonding and control in a family is described in this model through analyzing the cohesion and adjustment dimensions . The cohesive dimension of the family systems refers to the efforts that members invest in shared activities in order to stay together but also maintaining healthy emotional boundaries between each member and subsystems in the family . Still, families that describe themselves as too cohesive or flexible are the ones that develop problematic symptoms . When a family experiences stress, an adverse event, a traumatic event, or a life change , the family enters a period of adjustment. During this adjustment period, the family system must adapt and change the way in which it functions . The adjustment dimension is defined as the ability of the family system to change its structure and associated roles and responsibilities . The survival and strength of the system is dependent on the capability to evolve over time and adapt to the developmental stage of each member and family subsystem . It is important to know that too much flexibility in a family makes them interact chaotically , while low flexibility prevents the family from adapting to changes of the environment . Thus, extreme adjustment is maybe important when facing adverse events and not as a norm within the family. Family life and its incremental role for individual's quality of life is well debated and described as relevant for the psychodynamic development of young people . Taking into consideration the systemic view of the family, theory supports the fact that family members are each negatively affected when there is an unhealthy relational system in the family . The circumplex model of family functionality takes this aspect into consideration also by accounting the perceived real and ideal level of family functionality for members. Thus, the model assesses both the relational and the intrapersonal level of family functionality. Concordant with this dynamic model, the self-discrepancy theory argues that people organize and feel according to a set of internalized states about themselves and a higher gap between the real and ideal perceived levels results in emotional vulnerability and discomfort . Frain and colleagues also describe quality of life as a perceptive outcome of their position in life, but taking into account personal goals, expectations, standards and concerns. Therefore, it is important also to assess not only the level of agreement or conflict between members, but also the reflected and perceived discrepancy between the individual conflicted views of one's family, between the real perceived family functionality and the ideal family functionality that the adolescent perceives. Thus, the general hypotheses exploited here follow this line, that a higher gap between the real and ideal level of family functionality would decrease the quality of life, both mentally and physically. As studies show, teenagers and adolescents' perception of discrepancies regarding their family and life is important for their emotional quality of life . Another study showed using longitudinal data that discrepancies in perception of family functioning were associated with adolescents` life satisfaction, but they rather support a bidirectional relationship, based on theoretical reasoning . More important, it seems that the results support a greater negative relationship between discrepancies and psychological well-being for girls than for boys due to individuation and internalizations processes of adolescents within a family. Still, these studies mostly used differences scores, or they need more data to support these relationships overtime. The most recent work of Ohannessian, Laird and de los Reyes explored the discrepancies in adolescents and mother perception by analyzing the similarities between them and the results support the need to undertake a more accurate data analysis strategy. Although the focus of this study was the mother's psychological symptoms, this study is an example of how dynamic the interaction between family members is. Finally, these studies only explored the association of these dimensions, or the discrepant views between adolescents and parent. These studies did not test directly the discrepancies in their intrapersonal perception, between the real and ideal image they have about their family. Moreover, these studies particularly explored emotional adjustment or psychological well-being, but not the quality of life. Thus, a key aim of this study is to account for the concordance between their ideal and real views about one's families and their functionality to predict variations within the individual. --- The Present Study From a theoretical perspective, family functionality and quality of life has been considered in a bidirectional model of association. In other words, it is common in practice and theory to take both perspectives into account. Sometimes, the relational system and its functionality is what determines how an adolescent feels but there are also many cases when the development of a teenager challenges the resilient development of a family system. Still, from a scientific and practical point of view, these relationships are hard to analyze, therefore the literature is not that extended in this domain. So far, family functionality has either been explained as an outcome of adjustment or maladjustment for how adolescents feel and act, but not too often as a determinant for the adolescent's quality of life. Given limitations of the literature and the opportunity to use a complex model describing family functionality for both the real and perceived levels, the present investigation was designed to explore the discrepancies between the real perceived family functionality and the ideal family functionality levels that adolescents registered and how this would affect their quality of life. --- Method --- Participants and Procedure The participants were recruited in a medical setting, within a general hospital for children and with the help of the psychologist and the available nurses. A number of 139 chil-Tofan dren belonging to the Roma minority population completed the questionnaires and for each of them a consent was asked from the parents prior to filling out the survey. All of the adolescents that completed the questionnaire were enrolled in a formal educational institution corresponding to their age. The age of the participants ranged from 12 to 17 years as follows: 20,2% are 12 years old, 19,9% are 13 years old, 37,6% are 14 years old, 8,3% are 15 years old, 7,3% are 16 years old, 7,3% are 17 years old. Out of 139 participants, 38% are boys and 61,5% are girls. All of adolescents completed the questionnaire after we obtained verbal and written consent from one of their parents. Participants completed the assessments voluntarily, we assured them that their answers are confidential and that their parents do not have access to their evaluations. --- Instruments All participants were asked to complete the survey containing demographic questions, family functionality levels and the extended quality of life questionnaire. The Family Adjustment and Cohesion Evaluation is a scale with 20 items grouped into two dimensions concerning adaptability and cohesion of the family system. In order to assess the real and the ideal levels of the dimensions, the items were doubled. Cohesion of the system refers to the extent to which the members of the family manage to stay together and also maintain very clear borders between individuals and also their specific system. The evaluation is made by taking into consideration of the following aspects: emotional involvement, independence, borders, coalitions, space, friends, taking decisions, interests, and free time. Adaptability refers to the family`s ability to change the structure of power and roles, based on encountering stressful situations . Adaptability is measured through taking into consideration the rules within the family regarding discipline, control, the possibility to express autonomy within family, style of negotiation, role complementarity, relational rules and self-regulation mechanisms. Participants were asked to assess on a Likert scale to what extent these items define their family and how they would want it otherwise to be . The Quality of Life Questionnaire consisted of two component summary measuresthe physical quality of life and the mental quality of life. The physical quality of life refers especially to the following subdimensions: physical functionality, physical role, general health, and bodily pain, while the mental component refers to vitality, social functioning, role-emotional and general mental health. The assessment is mostly used in clinical settings to assess the general health of individuals and their capacity to face daily activities. The questionnaire was used for research with the permission of QualityMetric Incorporated. The organization provided the Romanian version of the scale and only the items regarding work activities were adapted to activities specific to the age of the participants . The data were computed using the specific manual instructions given by QualityMetric Incorporated. --- Data Analysis To assess how discrepancy between the real and ideal aspects of family functionality influence their quality of life, polynomial regression was computed. We used polynomial regression to explore the impact of the discrepancies between the real perceived level and also the ideal one. The regression coefficients were then plotted in the response surface analysis using IBM Statistics 21 and Microsoft Office Excel 2013 spreadsheet available online for use . The results were interpreted by examining the graphic and through testing and interpreting calculated surface values. First, I inspected how many participants would be considered to have discrepancies between the predictors . The agreement and discrepancy analysis revealed that almost half of the sample has discrepant scores . The results are illustrated in Table 1. Secondly, a similar analysis was computed to assess the discrepancies regarding family adjustment. The analysis revealed that more than half of the participants registered discrepancies regarding family adjustment . Based on data, I can conclude that exploring how discrepancies between these perceived levels of family functionality relate to quality of life makes practical sense. The second step was to conduct the polynomial regression and each predictor was centered on the mean of the scale. The analysis was made using the squares of the centered predictors and their cross-product of the centered variables in order to explain the interaction of the variables and the impact of the interaction. Table 3 andTable 4 illustrate all the results of the analysis with both unstandardized beta-coefficients and calculated surface values. --- Results Response surface analysis allowed to examine agreement between the two levels of family cohesionthe real and idealand how this relates to physical quality of life . As results show, most of the relationships regarding the impact of family functionality and quality of life are significant, but we also note that the analysis emphasizes the need to address the data in a nonlinear manner for physical quality of life. Therefore, the results are discussed here in an exploratory manner, indicating the tendency for results and the impact that the discrepancy between the real and ideal levels could have over physical. There is a linear predictive relation for mental quality of life, so we discuss the conditions of this relation and analyze the agreement and discrepancy level between the real and ideal Tofan A significant and positive relationship of perfect agreement between the real and ideal levels regarding family cohesion was found to predict physical quality of life , and mental quality of life . Moreover, there is no linear relationship along the line of perfect agreement because the non-linear slope of the line of agreement is also significant and negative for physical quality of life . Thus, the physical quality of life could increase or decrease more sharply as both the perceived real and ideal family cohesion become lower or higher from some point. Regarding the discrepancy between the two levels, the results show that physical quality of life is not significantly predicted along the line of incongruence , but the direction of the discrepancy is significant and positive , indicating a tendency that physical quality of life is more increased when the ideal level of the family cohesion is higher than the perceived real level of family cohesion. The line of incongruence and the direction of discrepancy regarding mental quality of life are significant and negative , indicating a tendency that adolescents register lower levels of mental quality of life when there is a higher gap between the two levelsthe real and ideal. Regarding the direction of the discrepancy, mental quality of life is higher when the real perceived level of family cohesion is higher than the ideal level of mental quality of life . Regarding the other family functionality dimension, adjustment seems to predict physical and mental quality of life in a nonlinear pattern . The general results show that there is an impact of family adjustment over adolescent's quality of life, both physical and mental one. ), where b1 is beta coefficient for real adjustment and b2 is beta coefficient for ideal adjustment . a2 = , where b3 is beta coefficient for Adjustment_real squared, b4 is beta coefficient for the cross-product of Adjustment_real and Adjustment_ideal and b5 is beta coefficient for Adjustment_ideal squared. a3 = . a4 = . b is unstandardized regression coefficient, se is the standard error. Significance depends in part on standard errors, thus a values of equivalent magnitude may not both be significant. *p < 0.05; **p < 0.01. --- Tofan In this model, the surface tests resulted in a negative significant relationship along the agreement slope, but with a significant value along the nonlinear relationship slope for both physical and a non-significant mental quality of life . Moreover, the line of incongruence shows that both mental and physical quality of life increases sharply when there is a higher discrepancy between the real and ideal levels of family adjustment. The direction of the discrepancy shows that both of the mental and physical quality of life are higher when the ideal level of family adjustment is higher. --- Discussion --- Summary and Interpretation The purpose of this research was to investigate how family functionality would impact quality of life. More specifically, family functionality cohesion and adjustment were assessed on both the real and ideal desired levels and examined their impact over physical and mental quality of life. Using a polynomial regression, the analysis examined whether similarity and discrepancies regarding the real and ideal levels of family functionality would have an impact over physical and mental quality of life. The general results are concordant with other studies that support the fact that life satisfaction is an important area for adolescents, in both the physical and mental ones . The results suggest that both mental and physical quality of life of adolescents are predicted by family cohesion and family adjustment . The general models show that concordant to the self-discrepancy model , a discrepancy between the two levels, the real and ideal ones, could act as a risk factor for physical and mental vulnerability or dissatisfaction. Thus, a discrepancy between the real and ideal levels regarding family cohesion do have an impact over adolescent's mental quality of life , but the results specifically show that only the direction of the discrepancy significantly matters, mental quality of life is higher when the real family level is higher than the ideal one. Although surprising, these results could be explained by the fact that although maybe adolescents tend to try to gain more inde-Tofan pendence, a warm environment in the family is still a supportive factor for when they face health problems and feel uncomfortable and unsatisfied . The results showed that a greater gap between the ideal and real levels of family adjustment is beneficial for the mental and physical quality of life of adolescents. The results are not contrary to the general model of self-discrepancies and its effects over one's health and emotional life . The direction of discrepancy shows that adolescents register higher levels of quality of life, both mentally and physically, when the ideal level of family adjustment is higher. Taking into consideration that the adolescent period in one's life is one characterized by the need to exert control and trying to gain more and more independence , it is normal that they would feel more satisfied if they start deciding more for themselves. Moreover, it is only natural that adolescents would feel more satisfied if in their family was more flexibility, but this is not an internalized standard that they live by and it is possible that this is why the gap between the two of them does not affect them. Thus, comparing the two perceived levels is probably a form of exerting autonomy and trying to define an important and deciding role in the family. Finally, it is possible that this need for flexibility and more power within the family to be desired in some areas of the family life and is not necessarily an internalized and valued standard for them that they wish to acquire. Moreover, although they would feel more satisfied, a more in-depth analysis would be interesting on how this need for flexibility would bounce back for the whole family system and each member and how is this dependent to age, especially because too much flexibility in a family is a risk for chaos within the interactional and relational family system . Still, the satisfaction of adolescents, both physical and mentally are salient in their life and it drives their life, so it is important to understand that this area of life needs to be managed properly by them and their family members. Finally, although their satisfaction is greater, this does not mean that they would also have healthy interactions and become more resilient consequently. --- Limits of the Study The results of this study should be interpreted considering its limitations. First, having participants subjectively rate themselves in variable could generate a social desirability bias. Still, the present study allowed participants to assess their family functionality taking into consideration both the real and ideal levels, continuing the steps already started on evaluation of the functioning of families in Romania . This assessment allows them to reflect over their family and express their desires and the way this would make them feel more satisfied. Secondly, the sample here is a conventional one and this may affect the extent to which the results can be generalized. Another limitation could be the sample size, and this can affect the significance of the relationships, but most of the results are significant in the suggested models. Moreover, the data analysis strategy is more accurate in explaining the effect of similarities and discrepancies. Thirdly, the data here are not registered in time, and so future research should consider that the results also show nonlinear patterns within this dynamic. Another limit for understanding the role of agreement or discrepancy of the ideal and real levels of family functionality for physical quality of life could also be the fact that Tofan adolescents here were already experiencing medical problems that may vary in pain and discomfort for them. Finally, despite its limitations, the results add to the exiting body of literature, emphasizing the complex effects of family functionality on general quality of life . Thus, the results support the idea that the individual perceived experience of adolescents could shape their quality of life and reveals that it is different than for adults in some respects. --- Other Considerations --- Ethics Statement The study was reviewed and approved by the Ethics Committee of Faculty of Psychology and Educational Sciences, Alexandru Ioan Cuza University of Iasi before beginning the study. All participants gave written informed consent in accordance with the Declaration of Helsinki. The written consent was given by both parents and children. --- Data Availability Statement The raw data supporting the conclusions of this article will be made available by the author by email, without undue reservation. --- Conflict of Interest The author declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

The perceived discrepancies of adolescents regarding family functionality (the real vs. the ideal) and how it predicts their mental and physical quality of life are tested. A cross-sectional study using questionnaires was conducted. Roma adolescents (N = 139) with ages ranging from 12 to 17 years participated. Out of all, 38% are boys and 61,5% are girls. Results show that mental quality of life is predicted by family cohesion and family adjustment and suggest a nonlinear relation for physical quality of life. The discrepancy between the real and ideal levels of family cohesion determines adolescent's mental quality of life. The direction of the discrepancy shows that mental quality of life is higher when the real family cohesion level is higher than the ideal one. The results suggest that both mental and physical quality of life of adolescents are predicted by family cohesion and family adjustment. People tend to thrive while having an image about themselves and they form this image by considering an ideal or a necessary way of being. Comparing the ideal to the real and present image of themselves people might experience maladjustment and could determine their mental health. The results of the study show that family cohesion and family adjustment perception of children determine their quality of life. Moreover, discrepancies between the ideal and real level are also an important determining factor for quality of life.

Introduction Proverbs are common in all human cultures. Their lack of specific authorship endows them with the significance of folk philosophy, encoding folk wisdom that encapsulates whole ranges of human experiences in science, engineering, technology, leadership, and other aspects of public culture. The proverbs of the Muslim Hausa of northern Nigeria are steeped in mostly Islamic moral philosophy, the Hausa being Muslims since 12th century. Despite the passage of time, Hausa proverbs have remained as constant as the moral situations necessitating their creation. So far, proverbs have remained straightforward conversational and traditional dialogues, i.e., rooted in folk tradition. However, with increasing urbanization and changing dynamics in social interactivity, proverbs are also changing. These changes, mainly minor alterations to the original proverbs, often add a new meaning to the same proverb. The proverbs that have emerged out of alterations to original proverbs are variously referred to as 'antiproverbs' and 'postproverbials' . While these proverb variants are also present in, especially, modern Hausa proverbs, the introduction of modern communication technologies and social media platforms in Hausa societies have contributed to the creation of new forms of proverbs. This is especially true among young users of such platforms that often rework old proverbs or create new proverbs based on the use of such social networks or their underlying communication technologies. I refer to these reworked or completely new proverbs that are based on new media technologies as 'neoproverbs'. I make this distinction right away to link neoproverbs with communication technologies . New Hausa proverbs not rooted in the technological domain remain that-new proverbs . This paper contributes to the debate on the transformation of proverbs in a traditional society by analyzing at least three clusters of modified proverbs in a collection of contemporary Hausa oral culture and paremiology. The first were straightforward 'antiproverbs,' as defined by Mieder and Röhrich , or what Raji-Oyelade labelled 'postproverbials'. The second are what Usman refer to as 'parallel' proverbs. These are Hausa proverbs with similar roots and meanings but are applicable to different contexts. While acknowledging these two categories as part of the flow of Hausa paremiology, my main focus is on the emergence of neoproverbs on social media The paper starts with methodology and then provides the contextual development of proverb alterations in various countries in order to situate the emergence of Hausa neoproverbs within the larger matrix of paremiology. It then presents the emergence of neoproverbs as those located within the social realities of new media technologies. --- Sources and Methodology This research is qualitative, and does not set out to measure any variables, relying as it does on textual data gathered from online or unidentified individual sources. Although it recognizes critical discourse analysis as the study of written or spoken language in relation to its social context, it does seek out authors or audiences of the texts to critically examine their motives or the context of their usage of the harvested proverbs. This is deliberate, as the approach adopted approximates critical ethnography, which "relies on the qualitative interpretation of data as this examines particular social, cultural, or organizational settings from the perspectives of the participants involved" . The data for this paper were harvested from three sources. The first was three authoritative compendiums of traditional Hausa proverbs . These provided a corpus of common, traditional proverbs that have retained their classical Hausa folk structure and have remained unmodified. The proverbs documented in these sources serve as a base for comparison with any modifications or the creation of original proverbs. The second source was community conversational groups in Hausa cities These 'hangouts' are often referred to as 'majalisa' in Nigerian Hausa communities, and they serve as a gathering place for conversations and, subsequently, places to hear a variety of proverbs. I have been an active member of two of such groups in the city of Kano, northern Nigeria, since adulthood. The third source for the data was online forums that I actively participate in, such as Facebook, Instagram, and WhatsApp groups with significant Hausa Gen Z populations, all posting in the Hausa language of northern Nigeria. Indeed, as of November 2022, Facebook alone had dozens of different groups dedicated to Hausa proverbs that provided a rich source of data on neoproverbs and their use among young people in Hausa societies. These online proverbs are categorized into two groups. The first was those that altered existing proverbs using information technology as modifiers. The second are proverbs that do not refer to any existing proverb and are, essentially, new. Their only relationship to existing proverbs is semantic similarity. The ethical issues of this Netnographic method were addressed by the fact that I was not anonymous in these groups, nor was I actively participating. At the same time, moderators of the groups often requested user-input in discussions of new proverbs. Thus, the sites of my data collection were not bound by privacy or confidentiality concerns. --- Proverbs and Their Transformations As Mieder pointed out, "of the various verbal folklore genres , proverbs are the most concise but not necessarily the simplest form". Their complexity is reflected in the way they encapsulate social philosophy, particularly for communities that do not have what I may refer to as 'authored philosophies'. Yankah observed that some "scholars like Walter Ong have associated proverb use with nonliterate societies, based on the argument that the mind cannot engage in analytical organization of thought without writing". Yet, as Whiting argued, a proverb is "a short saying of a philosophic nature, of great antiquity, the product of the masses rather than of the classes, constantly applicable, and appealing". Proverbs are contested as reflective of the social philosophies of their communities, not just quaint 'non-literate' societies. Further, Hatipo glu and Daşkın suggested that proverbs have been defined in various ways. There is the structural approach, which describes proverbs as propositional statements including at least a topic and a comment . Others approach the study of proverbs from ethnographic and cultural perspectives, which see proverbs as typically spoken, conversational forms whose sources are not known and which usually have a didactic function . Still, others prefer to follow an empirical approach, which helps them study the modifications to proverbs . However, I adopt Wolfgang Mieder's definition that "a proverb is a concise statement of an apparent truth which has, had, or will have currency among the folk" . The cultural significance of proverbs is often reflected in its community value as a community memory. African societies conduct the vast majority of their social discourse through oral literature, and proverbs provide a very easy outlet for this. Proverbs express thoughts effortlessly and encapsulate social and communal philosophies. They also reflect life's truisms and serve as a moral compass. As Kirk-Greene pointed out, [p]roverbs enshrine much of the cultural heritage of a people-their traditions, their history, their wisdom and their ethics. More than this, in the absence of a rigorous written literature, they may serve as the guardian and carrier of a nation's philosophy and genesis. Within this context, proverbs in Africa acquire a high social value that elevates them to an art form. Thus, according to Raji-Oyelade , Major scholarships on African proverbs have sustained the idea of the sacrosanct structure of the proverb text. I want to argue that the notion of the fixity of form is almost contradictory to the original idea of the dynamisms of societies and cultures, that it is impossible not to recognize a certain radical shift or the transgressive force in the making and use of proverbs in recent times. Perhaps because of their rootedness in folklore, the historiography of communities, and social dynamism, Litovkina et al. cautioned that [p]roverbs are by no means fossilized texts but adapt to different times and changed values. While antiproverbs can be considered as variants of older proverbs, they can also become new proverbs reflecting a more modern worldview. In Europe and North America, the genre of transformed proverbs is becoming ever more popular, especially due to the mass media and the Internet. The changes to proverbs provide a fascinating example of transformation in oral literature and also reflect the dynamism of language and discourse. In Africa, these transformations reflect a new shift towards postcolonial oral discourse. As Akinsete argued, with the fast-changing modern African society in view, the interrogation of the postcolonial has continued to generate intriguing perspectives. The effervescent discourse of decolonization, as expressed in arrays of literatures, divulges among other issues the rhetoric of change/adaptation in postcolonial African space. Structurally, proverbs as complex sentences are made up of a topic and a comment. These translate as one clause and one or more subclauses; the subclauses may be adjectival, nominal, or adverbial. The structural balance in these proverbs is asymmetrical, with the subclause being dependant on the main clause In the Hausa bipartite structure of proverbs , the subclause would not stand on its own and has no discernible meaning outside of its relationship to the main clause. Two different terms have been given in paremiology for the alteration of the subclause in a proverb. The first was by Wolfgang Mieder and his colleague Lutz Röhrich , who coined the German expression 'Antisprichwort' for this alteration, and popularized it as a general label for such innovative alteration of and reactions to traditional proverbs . Mieder explained antiproverbs succinctly as "parodied, twisted, or fractured proverbs that reveal humorous or satirical speech play with traditional proverbial wisdom" . He further pointed out that: the conscious manipulation of so-called fixed proverbs is absolutely nothing new. After all, proverbs are anything but sacrosanct pieces of universal wisdom. Instead, they express generalized observations and experiences that are as varied as life itself. The second term for altered proverbs was by Raji-Oyelade , who argued that the "supplementary proverb, the product of which may be inadvertent or unintentional, is what I call the phenomenon of the postproverbial" . He further held that the postproverbial is "situated in the subfield of transgressive paremiology . . . of alternate proverbs which are radical and parallel compositions instead of conventionally accepted and given proverbs in traditional societies" . It would appear from the various studies available that postproverbial, as a term, was adopted not only by Raji-Oyelade but also by other African paremiologists . However, neither Mieder nor Raji-Oyelade considered the status of newly formulated proverbs, rather their interest was on the alteration of existing ones, especially those infused with social media referents. Thus, I coin the term 'neoproverb' for the category of proverbs that have their origins wholly in internet technology. Further, besides the use of different terms, it is not clear what differentiates an antiproverb from a postproverb, except that the latter is more applicable to African proverbs and tied up with the notion of postcoloniality. As Raji-Oyelade and Oyeleye noted, postproverbiality is purposively named and situated within a string of 'posts'. As such, postproverbials are postcolonial, poststructural, postmodern, linguistic reinventions. They are postcolonial in the African/Third world context since their use and popularity became noticeable post-colonial. They are poststructural because they stand at variance with the norm and are responses to a pre-existing structure-proverbs, whose secure sense of meaning they disrupt. The postproverbial is postmodern because it seeks to create 'a new from the old' through the use of playful parody and pastiche, which, as an imitation of another's style, prompts us that the text is not "original" but constructed. Thus, Raji-Oyelade and Oyeleye's interpretation of postproverbials as "playful parodies of the once sacrosanct African proverbs" integrates the very concept of postproverbials exclusively with African paremiology. This is confirmed with the development of the Postproverbials in African Cultural Expressions internet site, which describes itself as a "trans-national initiative which brings African scholars in the humanities together with the ultimate aim of contributing to the body of modernist and radical proverbs which are created mainly in urban communities almost all over the African continent". The initiative was supported by the Institute of Asian and African Studies, Humboldt University of Berlin, Germany. The PACE site contains Postproverbials in Efik, Fuláe, Hausa, Mwaghavul, Yoruba, Igbo, Ibibio , Gikuyu , Akan, Kasem , Kiswahili , Luo , and Shona . Perhaps not surprisingly, the site was curated by Raji-Oyelade . Indeed, this term is rarely used by non-African paremiologists. Yet, Iyabode Daniel disagreed with the notion of 'blasphemy' that Raji-Oyelade's 'postproverbial' theory suggests is implied in a proverb. She points out that in the age of smartphones and tablets that are handheld and not to be swallowed, the wisdom of the present age has moved from the elders to the young. One can argue that this is a kind of wisdom and not necessarily cultural wisdom. That may appear true. However, we should not forget that cultural wisdom also has to do with cultural dynamism. Similarly, Okhuosi argued that, although postproverbiality is a development from proverbiality, this transition is not limited to the semantic sense of time only; it is also the radical revisions of conventional proverbs among the youths. It is characterized by wit, humour, modernisation, ideological radicalism. It draws heavily from the syntax and semantics of the wealth of traditional proverbs but reproduces them through the deconstruction and infusion of modern ideologies. However, according to Raji-Oyelade , "postproverbials are translatable in Yoruba as ás . ákas . á, that is, the dynamic act of the cultural deviant, the prodigal text which always attempts to overwrite its own source". Similarly, Yakasai , in his analysis of social media proverbs, noted that [a]lthough the morphology, structure and semantics of the vast online corpus of Hausa idioms and proverbs have been severely damaged , it can be addressed by making and implementing language policy. In short, while the top-down language policies can help protect the normative aspects of language, the bottom-up language use shows the language characteristics of young netizens, which could be studied as a language phenomenon Both Iyabode Daniel and Ronke Okhuosi have introduced a dimension that deconstructs Raji-Oyelade's postproverbials as 'blasphemies' or as Yakasai's 'language pollution' . While allowing the term the dignity of its existence and applicability, as, for instance, demonstrated in a whole issue of Matatu, which was devoted to various articles on postproverbiality in Igbo , Fuláe , and Arabic , it is clear that its source as a label for modified African proverbs is in contention. Thus, Wolfgang Mieder and Adeyemi Raji-Oyelade force us to take a second look at the evolving nature of proverbs and the way the current social culture deconstructs them. It might be interesting to excavate further back to find that what we now see as deconstructions of what might be considered 'classic' folk philosophy indeed also evolved from a similar deconstruction of an earlier folkloric thought. Thus, in looking at the various iterations of proverbs, Mieder cautions that [i]t is not enough to identify hundreds of antiproverbs and place them into collections organized according to the original proverbs followed by the altered texts or thematically by the subjects and meanings of the antiproverbs. Scholars must also interpret the use and function of anti-proverbs in oral and written contexts and reflect upon the significance of this preoccupation with antiproverbs by the folk themselves. From these explanations about what constitute an antiproverb, what emerges is that an antiproverb must be based on a known proverb to have full effect. To illustrate this, Litovkina et al. and Mandziuk collected a series of antiproverbs from various sources, including literature, newspapers, films, and the internet. A few of these included the following: Classic: Man proposes, God disposes. --- Antiproverb: Man proposes, his mother-in-law opposes Classic: A friend in need is a friend indeed Antiproverb: A friend that isn't in need is a friend indeed Classic: What can't be cured must be endured Antiproverb: What can't be cured must be insured Each of these altered proverbs indicates a contemporary narrative that reimagines the original proverb to suit current perceptions of social culture. Similar perceptions are found in the Igbo language proverbs of south-eastern Nigeria. Egbara The social culture of the Igbo is reflected in these examples. For instance, the proverb about cleanliness and eating with kings suddenly became a contextual proverb that reflects wealth, and thus glorifies material acquisition higher than the dignity of sharing a meal with a revered elder. Enjoying what one sows is a syntactical variation of reaping what one sows. --- Modification of Hausa Proverbs So far there has not been a detailed study of Hausa antiproverbs, either in literary texts or on social media. The nearest was by Usman , who studied what she called 'parallel' proverbs. However, these were Hausa proverbs with similar roots and meanings but were applicable to different contexts. Thus, she quoted parallels as "elements of equal importance which are expressed in similar grammatical form" . For instance, she gave an example of a parallel proverb as the following : Proverb: In ka ga raÎumi, ka ga Buzu/wherever there is a camel, there is a Tuareg Parallel: In ka ga wata, ka ga Zara/wherever you see the moon, you will see Sirius In the first proverb, 'Buzu' was an onomatopoeic appropriation of the word 'buzuzu,' which refers to the common variety of dung-beetle , a term thus indicating a short-tempered person. Since the Tuareg were perceived by the Hausa as being easily provoked and short-tempered, the shortened term, Buzu, came to refer to them. Camels are used as a form of transport across sand dunes by the Tuaregs throughout the Sahara, and thus, they came to symbolize each other. In the second example, a similar juxtaposition is involved where pairings are noted. The coupling here refers to the moon appearing almost at the same time as the dog star, or Sirius. The Muslim Hausa refer to Sirius as Zahra, which means 'bright'. A variation of the term is also used a female name. As interesting as these parallel proverbs are, they nevertheless represent contextual, different circumstances that have led to similar observations. They are not subversive, or as Raji-Oyelade would describe, blasphemous, since they are only intertextual to the originals. These differ from true Hausa antiproverbs. --- Hausa Antiproverbs A collection of Hausa antiproverbs collected from interaction with people at community hangouts in the city of Kano, northern Nigeria, reveals that they use substitution devices, just like other antiproverbs. In so doing, they modify, extend, and often amplify the original proverb by providing a new, often contemporary narrative meaning to the base proverb. For this device to work, the antiproverb subclause must be connected to the main clause of the old one. Below are five examples that show the universal character of antiproverbs: #1: Proverb: In kaga gemun âan uwanka ya kama wuta, shafawa naka ruwa/if your neighbor's beard catches fire, wet yours Antiproverb: In kaga gemun âan uwanka ya kama wuta, aske naka/if your neighbor's beard catches fire, shave off yours This 'classic' proverb about beards is both antiproverb and also seen as antisocial, because the proverb seems to encourage selfishness-instead of rushing to help a neighbor in distress, the protagonist is busy protecting himself, thus categorizing the proverb as what Doyle called a counter-proverb, because of its negation. The antiproverb, then, is a deeper immersion of the same cautionary behavior reflected in the original. #2: Proverb: Da tsohuwar zuma, ake magani/aged honey has best medical properties Antiproverb: Da tsohuwar zuma gara sabuwa/rather a new honey than an aged one This proverb is derived from an Islamic description of the properties of honey in the Qur'an . Honey is generally used by Hausa Muslims in most variations of alternative medicine. The antiproverb reflects the same philosophy but in a new social terrain-accepting the curative powers of honey, but believing a newly produced honey is better than an aged one that might have been contaminated or rendered impure. The proverb and the antiproverb both challenge the widely held belief that honey does not 'spoil' no matter how aged, especially if not mixed with some preservatives . Unlike wine that is said to get better with age, they consider the healing potency of honey as being weakened by age. #3: Proverb: Komai nisan jifa, Îasa zai dawo/whatever goes up in the sky, will come down Antiproverb: Komai nisan jifa ba zai taáa sama ba/whatever goes up, will never touch the sky Many proverbs in all societies often have scientific connotations. The third example of Hausa antiproverbs demonstrates an understanding of the laws of gravity-what goes up, comes down. Yet the antiproverb does not blaspheme the original in suggesting that no matter how high a stone is thrown up, it will never touch the sky; indeed, it reinforces the pull of gravity , confirming the validity of the original proverb. While the original proverb is also a reminder that good things will not last forever, in the Hausa ethnographic context, it keeps individuals rooted to their social realities no matter how successful they become. #4: Proverb: Kowa ya ci zomo, ya ci gudu/whoever eats a rabbit, will surely be a sprinter Antiproverb: Kowa ya ci zomo, ya ci daâi/whoever eats a rabbit, will have a delicious meal Rabbits are excellent sprinters, swiftly disappearing into their warrens, giving the impression in the Hausa proverb that whoever eats rabbit will acquire the same property of speed. The antiproverb is not convinced of the connection between eating a rabbit and becoming a sprinter. Indeed, no one is known to have acquired extra sprinting abilities by simply eating a rabbit. Thus, the antiproverb focuses more on the culinary property of the rabbit as a rare meat dish, by ignoring how it was caught. #5: Proverb: Bayan wuya sai daâi/relief follows difficulties Antiproverb: Bayan wuya sai haÎuri/patience follows difficulties Relief is expected as a reward that follows suffering . This proverb is based on two Qur'anic verses: "Fa Inna ma al usri Yusra. Inna ma al usri Yusra"/"So surely ease with every hardship. Verily, with hardship there is ease" . The overall effect of the proverb is to teach patience-a fact captured in the substitution with the insertion of 'patience' in the antiproverb. This particular substituted antiproverb has a recent and political origin, as it was coined in northern Nigeria to cope with perceived hardship in the regime of a once popular President whose policies were believed to have made life difficult for the masses throughout his presidency, which lasted from 2015 to 2023. In each of these examples, the subclause of the classic proverb encapsulating traditional Hausa oral literature is substituted to reflect a wholly different philosophy, often serving as antiproverb. --- Hausa Neoproverbs Hausa neoproverbs reflect the thinking of the Hausa Gen Z social cluster of the online community of Hausa speakers. This group became the source of neoproverbs as a result of their rapid embrace of urban life, modernity, and, indeed, postmodernity in all aspects of their lives. They are postcolonial without having experienced the colonial. Mostly born between 1997 and 2012, they occupy the same demographic as the global Gen Z youth cluster. According to Katz et al. : Gen Zers, also called postmillennials, Zoomers, or iGen-ers, are the first generation never to know the world without the internet. The oldest Gen Zers, now in their mid-twenties, were born around the time the World Wide Web made its public debut in 1995. They are therefore the first generation to have grown up only knowing the world with the possibility of endless information and infinite connectivity of the digital age. As 'digital natives,' they are cloistered in online communities with little human conversational interactions. This closed interpersonal space has at least two effects: first it creates a new linguistic ecology for them, and second, it shields them from what is 'normal,' enabling them to create their own new, normative behaviors. For this group, the availability of technology is integral to their lives and shapes their practices, languages, thoughts as well as their perceptions of public culture. They are, therefore, rich sources of proverbs that often have no antecedents, and they have created-without knowing it-what can be traditionally considered 'blasphemous' neoproverbs. All the Hausa neoproverbs appraised in this study gravitate toward the users' understanding and appreciation of and expertise in online communication. For these users, the online forums and the communities formed there have become new social media village squares, where people hang out and share perspectives. Online words and expressions have become part of their everyday lexicon. Perceptively, they pass judgements on the various devices they use to communicate, particularly phones. Such devices have also evolved into status symbols. Interestingly, this cohort of online users intensively employ code switching in their construction of neoproverbs, incorporating English as medium of expressing their newly created proverbs. This, indeed, adds a new dimension to the emergent neoproverbs, which have become necessary for them as a result of a lack of local translated equivalents for social media and communication technology terms. The neoproverbs in this study, which were collected from Facebook, conversational, and WhatsApp groups, as indicated earlier, are divided into three categories. The first are those that approximate antiproverbs in that, while their main clause is often rooted in a traditional proverb, their subclauses are firmly located within social media usage. Despite their traditional clauses, I prefer to name them neoproverbs because their subclauses are not modifications of the existing subclause of the proverb since there is no negation, but rather a completely new thought. The second are those wholly rooted in social media usage. The third are those in which both the clause and subclause are dependent on a communication device, particularly smartphones. The second and third groups have no antecedent origins in any prior proverb structure, as both the clause and subclause are wholly new creations. --- Neoproverbs with Social Media Clauses These are neoproverbs with a traditionally structured proverb clause, followed by a subclause based on social media, thus earning the 'neo' affixation. Examples include: #1: Proverb: Wanda ya riga barci, shi zai riga tashi/Early to sleep, early to rise Neoproverb: Wanda ya riga log in, shi zai riga logout/Early to log in, early to log out. The concept of 'log' in and 'log' out in the subclause is derived from the internet time purchased by young people at internet cafes in northern Nigerian cities. The time purchased was usually hourly, with a timer counting down to the end of the funds allocated. In a competitive spirit among those wishing to log in earlier, the proverb reminds them that they will also log out earlier. While the folk proverb clause is referring to the healthy benefits of sound sleep, the neoproverb harks at the curtailment of enjoying internet services. #2: Proverb: Duk abin da ruwan zafi ya dafa, in aka yi haÎuri, ruwan sanyi ma zai dafa/Whatever hot water boils, will also be boiled by cold water, if you are patient enough Neoproverb: Duk wayar da za ta yi Instagram, za ta yi WhatsApp/Any mobile phone that can run Instagram, can also run WhatsApp The folk proverb is about the virtues of patience, and the same philosophy is conveyed by users of mobile phones concerning the trending applications used. When Instagram became available in 2010, users of WhatsApp, which became available in 2009, felt that the latter application would not run on their mobile phones. This was clearly ill-informed by the perception that, as a result of the focus of Instagram on photographs, mobile phones running Instagram would not run the predominantly text-based WhatsApp. This reveals a lack of understanding regarding the dividing line between social media and social networks. While Instagram, with its emphasis on images and videos, is categorized as social media, WhatsApp, with its focus on conversations, is essentially a social network. #3: Proverb: Gaba da gabanta, aljani ya taka wuta/There is always a higher power, a spirit being has stepped into fire Neoproverb: Gaba da gabanta, an yi hacking account âin âan Yahoo/There is always a higher power, the account of a scammer has been hacked Spirit beings should not feel the heat of the fire; but when they do, things are decidedly serious. The folk proverb is drawing attention to the fact that no matter how large or intimidating a person or thing is, there is likely to be an even larger or more intimidating person or thing somewhere. The neoproverb captures this fairly with its reference to what in Nigeria are referred to as 'Yahoo boys' . These are usually young, male scammers and fraudsters adept at using the internet to extort millions from innocent citizens, especially in European countries, with false tales of either romance or economic investment . Hacking the account of a hacker captures the essence of 'there is always a bigger fish in the sea'. #4: Proverb: Komai nisan dare, gari zai waye/No matter how deep the night, there will be dawn Neoproverb: Komai nisan dare, sai ka samu wani online/No matter how late the night, there is always someone online While the folk version is about raising hopes-there is always light at the end of the tunnelthe neoproverb reflects an ethnographic reality of online addiction: there are always online users, a fact not lost on parents of Gen Z children. #5: Proverb: Tsintacciyar mage, bata mage/A stray cat is never a good cat Neoproverb: Tsintacciyar budurwa a Facebook, ba ta Îarko/A Facebook girlfriend does not last While cats are as adored in Hausa communities as in any other community across the world, there is a preference for known 'purebred' and fully house-trained cats. A stray cat could come with all sorts of unknowns, thus the folk proverb indicating a lack of trust for such stray cats. The neoproverb extends this notion to online Facebook friendships because Hausa communities prefer 'girl next door' romantic relationships with someone whose 'pedigree' is known. The neoproverb, therefore, warns against a 'stray' girl picked up on Facebooks as an unknown entity with unpredictable behaviors. However, in a reply, girls also came up with their own proverb that counters this, as I will show later. --- Neoproverbs with Clauses and Subclauses Based on Social Media The second dataset contains neoproverbs in which both the clauses and subclauses are based on social media and have no antecedents, as was the case in the first group. Examples include: #1: "Salam, good night", in ji sabon âan Facebook/Peace on you, says new entrant to Facebook. Typical of Muslim communities, every entrant into a new social culture begins with a 'peace upon you' . For many young Hausa having just acquired a social media account, particularly Facebook or WhatsApp, the usual greeting is 'Salam' before engagement with any thread of discussion. The greeting shows decorum, respect, and moral upbringing-even if the thread being discussed is somewhat less than desirable to the Hausa cultural universe. Jumping directly into a thread without the greeting is considered bad manners. A newly arrived member of any social media platform is, therefore, clearly visible by the way they enthusiastically announce their presence with the 'salam' greeting, and they are often the object of derision of being a simpleton who has just arrived to the social media world. In this, the Hausa online culture simply extends to in-person public culture. #2: An yi ba a yi ba, an daina Facebook, an koma WhatsApp/the same old thing, quitting Facebook for WhatsApp. When Facebook made inroads among Hausa communities, its potential for enabling free expression was frowned upon by the Muslim conservative establishment. Facebook was seen as being the home of all that was undesirable in Islam-despite many pages and groups promoting Islam. As a result, parents and community leaders started discouraging young people from using Facebook. A few years later, WhatsApp became available. Based on the personal space of an individual's phone, it offers more privacy and opportunities to engage in whatever behavior one wanted, including those frowned upon on the more public Facebook. Thus, the neoproverb is pointing out that 'the song remains the same'. #3: A yi dai mu gani, soyayyar soshiyal midiya/As if it'd last, social media romance. This references the emerging romance on social media platforms as a counterculture. The traditional pattern of Hausa courtship is based on in-person interaction between a boy and a girl at the girl's family house and always chaperoned by a younger female sibling of the girl, or at least in a semi-public space. This is to discourage impropriety, especially with overcharged hormones kicking in. Before assumptions of sexual awareness made possible by entertainment media engagement, boys and girls courted each other at night, again at the girls' house. Many Muslim states in northern Nigeria issued fatwas prohibiting such night courtship when a series of unwanted, out-of-wedlock babies started to appear in many households. An Islamic moral police force , where existing, was empowered to stop night courtship and shift it, if necessary, to late afternoon after the last daytime prayer. When social media became available, courtship shifted online, but participants felt it lacked the soul and authenticity of in-person courtship, as speech nuances and body language, essential in Hausa non-verbal communication and indicators of true affection, cannot be judged. The general feeling among a few Gen Z social media citizens engaged in this topic believe that such social media romances rarely last, as the pictures used as avatars are carefully composed to attract romantic partners and, therefore, do not reflect the true nature of the owner. Thus, this proverb casts doubt on the authenticity of online courtship. #4: Tsit ka keji, uwar gulma tayi cikin shege a social media/You could hear a pin drop on social media, a gossipy woman has an unwanted pregnancy. "Uwar gulma" is a gossipy woman who cross-pollinates gossip from one person to another, and is always broadcasting bad news about other people, especially on the social media. When she becomes pregnant out of wedlock, her social media handles become completely silent. The metaphor also refers to the extremely textually vocal nature of social media messaging, where there is always someone saying something, no matter how late the hour. #5: Aikin kenan, a chatting, budurwa ta gama Sakandare/Constantly at it, nothing but chatting, a young girl has finished Secondary School. This reflects a sense of freedom for mainly young Muslim girls who are usually thought of as best 'seen, not heard'. Hausa girls usually attend a highly regulated high school, with little conversation and certainly no phones or other forms of technical communication. The proverb, therefore, captures the celebration of vocal freedom when a young lady finishes high school and, subsequently, has all the freedom she craves through chat rooms. 4.6. --- Neoproverbs Based on Smartphones These are neoproverbs with a general focus on telephony, but with specific reference to and preference for smartphones. In these neoproverbs, neither the clause nor subclause are dependent on any prior folk proverb, though they borrow the general syntactic structure of a typical Hausa proverb. They are rooted in the technologies of mass communication. Both Mieder and Konstantinova covered proverbs on mass communication, but in different ways, and certainly different from my conception of neoproverbs as rooted in communication technologies. For instance, while Mieder has discussed proverbs based on mass communication, his samples were what could be referred to as substituted proverbs, since they only shared onomatopoeic structure with an 'original' proverb-nothing actually linked the original with the substituted, especially for those unaware of the originals. Mieder was dismissive of these 'anti-proverbs,' suggesting that "there is no doubt that most anti-proverbs are one-day-wonders in that they will never enter general folk speech by gaining a certain currency and traditionality" . Examples include Mieder : The medium is the message/The modem is the message Pennywise, pound foolish/Pentium wise; pen and paper foolish Beware of Greeks bearing gifts/Beware of geeks bearing GIF's The meek shall inherit the earth/The geek shall inherit the earth Don't bite more than you can chew/Don't byte off more than you can view It could be argued that, strictly speaking, these are idioms-often cryptic phrases with their own meaning-rather than pure proverbs, which have advice to another person ingrained in them. Even at that, the anti-proverbial nature of these examples is located in a totally different social culture from that of the 'pure' idiom. Thus, despite their being rooted in technology, I do not accept these examples as neoproverbs-perhaps they are neo-idioms. I make this distinction to further clarify the nature of what I regard as neoproverbs. On the other hand, Konstantinova merely quotes various characters in news reels, TV shows, and journalists' reports using proverbs, thus focusing on the frequency of the utilization of proverbs in mass media discourse. The first mobile phones available to Hausa youth in urban clusters were cheap ones from lower end Chinese companies. An early affordable model was from Vivo Communication Technology Co. Ltd., with their phones being marketed and stylized as vivo™. The low-end phone market was soon joined by Tecno™. Although both companies eventually marketed smartphones with full android operating systems, their earlier models used Symbian operating systems. The iPhone then, and still now, being the highest end smartphone was affordable only to the extremely wealthy. Children of such a class usually end up with lower versions of the iPhone when their parents or relatives move to a newer model. The iPhone has thus become a status symbol and is enviously looked upon by owners of cheaper phones. When Google introduced the Android operating system for other phones, the youth who did not have the financial means to upgrade to an Android phone were stuck with Symbian OS phones. They became the butt of new social media technology proverbs. Such proverbs serve as both neoproverbs as well as a flouting of class differences. Examples include: #1: Zagi ai ba ya Îari, wai an ce da mai vivo™ buâe iCloud/Insults don't result in a tumor, a vivo™ owner has been challenged to open an iCloud account. Since the early Symbian vivo™ phones had no iCloud facilities, users of iPhones are flaunting their iPhone's capabilities for such services. iCloud, launched in 2011, is a service from Apple that securely stores users' photos, files, notes, passwords, and other data in electronic 'cloud' storage. The iCloud has become critical to phone users who do not have any means of storing the increasingly large numbers of pictures they take with their phones. A variation of elitism in phone ownership is a neoproverb, which states the following: #2: Abin na manya ne, mai vivo™ ya ga mai iPhone ya na âaga selfie/These are the true elites, a vivo™ owner on seeing an iPhone owner taking a selfie. The self-portrait taken with a smartphone camera also has also come to represent ultimate urban cool and modernity among Hausa youth, especially those with iPhones and before the advent of lower-end smartphones. Their ability to take personal photographs in various locations performing various acts has become another status symbol, something owners of lower-end phones have no access to. The proverb, therefore, reflects such class division. #3: Komai daâin 2go, bai kai ya WhatsApp ba/No matter how good 2go is, it is not a touch on WhatsApp. The app 2go is one of the few African mobile messenger social network services that caught the attention of many young people in Africa when it first appeared in 2008. When WhatsApp appeared a few years later, it replaced 2go as the most popular social networking application for mobile phones. Despite its popularity, though, there are those who remained loyal to 2go and refused to switch to WhatsApp. This proverb is a celebration of freedom from 2go, for despite its familiarity, the protagonist prefers WhatsApp, apparently with better services. #4: Namiji kamar service âin waya yake, yanzu zai kawo yanzu zai âauke/A man is like a network service, now you get him, now you don't. This neoproverb is a reflection of intergender feelings among young Gen Z users of Hausa social media. It alludes to the unpredictability of a steady boyfriend, as it likens a steady relationship to the fluctuating nature of network services, which are very erratic in Nigeria. It is reply to the male proverb stating the unpredictability of a Facebook girlfriend. Militz and Militz remind us that proverbs in actual use are verbal strategies for dealing with social situations. To understand the meaning of proverbs in actual speech acts, they must be viewed as part of the entire communicative performance. Neoproverbs, under the guise of whatever terminology, are clearly referring to a folk proverb, either in semantic structure or in reimagining. I argue that they are neither fractured proverbs , nor disruptive cultural deviants that are radical, parallel compositions . They do not negate, reverse, or blaspheme. They simply reflect younger Gen Z users of social media creating new proverbs that reflect contemporary social cultures and conversational practices. Regretfully, there is an insufficient focus on the emergence of new proverbs, for as Wolfgang Mieder noted, "[it] must, however, be said that scholars hitherto have simply not paid enough attention to the creation and emergence of new proverbs" p. 113. --- Conclusions Further, the power of the English language as the internet language in northern Nigeria has created linguistic situations where English or technical words that have no local language equivalents have been incorporated into the idioms, sayings, proverbs, and every day conversations of younger people in the area. Hausa proverbs documented by Merrick, Kirk-Greene, and Yunusa remain the classical references for 'pure' Hausa proverbs. This purity was maintained in them as a result of the closeted nature of Hausa societies before the advent of British colonialism . It is unrealistic to assume that such proverbs would continue to reflect the thinking of a social world confronted with the postcolonial flow of media products, including communication processes curated with information technology. True, as Mieder painfully reminds us, "[m]ost anti-proverbs are one-day-wonders in that they will never enter general folk speech by gaining a certain currency and traditionality." . Yet, with the increasing adoption of internet technologies as part of every language discourse among both urban and rural Hausa, neoproverbs promise to be part of sustainable, continuing, new folk wisdom in Hausa societies. Users of such wholly new or modified proverbs may not be aware of the original form of the proverb, and certainly those who create social media proverbs, or those inspired by communication technologies, do so not with the intention of distorting the original proverb, but of simply borrowing the syntactic structure of the traditional proverbs to express their own immersion. Musere notes that "African proverbs involve a wealth of 'disappearing' oral wisdom and tradition that begs for much further exploration". Yet, the continuous creation of new proverbs based on the usage of social media clearly shows a new direction in contemporary paremiology. --- Data Availability Statement: The data for this research was harvested from being part of personal conversation groups in the city of Kano as well as few random comments on various Facebook posts. The date is therefore unique and has not been archived on electronic means. ---

This paper interrogates the changing paradigm in the evolution of traditional African proverbs in the postcolonial setting in which Hausa youth create proverbs centered around the power of both social media and their technologies. In this context, the notion of colonized subjects, cowering under the glare of English linguistic imperialism, is challenged by the Hausa youth through newly fabricated social media proverbs that acknowledge English terms, but use social media platforms to convey what I call 'Hausa technofolk' philosophy. This provides insight into how contemporary African youth force a new narrative in the notion of coloniality.

Violence against women is recognized as a significant public health problem, with serious consequences for women's physical, mental, sexual, and reproductive health. The most common type of violence against women is intimate partner violence, which refers to any behavior within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship. Intimate partner violence during pregnancy that it may confer risks to the neonate through the mother's increased risk of premature birth, as well as the infant being at risk for low birth weight. This study focused on to examine the association between intimate partner violence during pregnancy and adverse birth outcomes. Women who gave birth in the selected hospitals, during the study period were interviewed during the study period. Women's who had been exposed to intimate partner violence during pregnancy were more likely to have low birth weight and preterm baby. Face to face interview was done to a total of 954 women who participated in the study with a response rate of 100%. The mean age of mothers was 28.37 ± 6.25 years' ranges from 16 to 48 years. Seventy of cases and 138 controls were living in rural areas. Regarding to marital status, 276 cases and 554 of controls were married. Two hundred nine of cases and 367 of controls were house wives by occupation and 43 cases and 85 of controls had not attended formal education. --- Background Violence is the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either result in or has a high likelihood of resulting in injury, death, psychological harm maldevelopment or deprivation [1]. Women's health and lives, in particular, are seriously affected by gender-based violence. Violence against women, committed by an intimate partner, is recognized as a significant public health problem and Human Rights issue. Violence by an intimate partner is manifested by physical, sexual or emotional abusive acts as well as controlling behaviors [2]. Though violence occurs in different forms and settings including workplace, school, and community, violence at home by intimate partner violence is considered as the most prevalent form [3]. According to UN declaration, violence against women includes "any act of gender-based violence that results in, or is likely to result in, physical, sexual or psychological harm or suffering to women, including threats of such acts, coercion or arbitrary deprivations of liberty, whether occurring in public or private life [4]. Global estimates published by WHO indicate that about 1 in 3 of women worldwide have experienced either physical and/or sexual intimate partner violence or non-partner sexual violence in their lifetime. Most of this violence is intimate partner violence. Worldwide, almost one third of women who have been in a relationship report that they have experienced some form of physical and/or sexual violence by their intimate partner in their lifetime [5]. Intimate partner violence is also widespread in Sub-Saharan Africa; surveys conducted in the region showed that 46% of Ugandan women, 60% of Tanzanian women, 42% of Kenyan women, and 40% of Zambian women reported regular physical abuse [6]. Intimate partner violence is a common phenomenon in Ethiopia both in urban and rural families. About 81% of women believed that a husband is justified in beating his wife. Surveys in Ethiopia have also reported that nearly one-half to two-thirds of ever-partnered women experienced intimate partner violence [7,8]. Women suffer physical, emotional, sexual and economic violence by their intimate partners. It is often protected by family secrecy, cultural norms, fear, shame, community's reluctance on the domestic affair and social stigma [9]. According to the Center for Disease Control of the United States, , pregnancy may represent a unique opportunity for the vulnerable woman to have contact with health care providers, making it an important time for the detection of violence during and after the pregnancy [10]. The prevalence rate of intimate partner violence during pregnancy ranging between 4 and 29% [11]. Intimate partner violence during pregnancy does not only affect the women's reproductive health, but also imposes fatal and non-fatal adverse health outcomes on the growing fetus due to the direct trauma of abuse to a pregnant woman's body, as well as the physiological effects of stress from current or past abuse on fetal growth and development [12]. A substantial amount of research supports that IPV during pregnancy confers risks to the neonate by increasing premature birth as well as the infant being at risk for low birth weight . LBW and PTB are well established leading causes of neonatal morbidity and mortality [13]. Given the magnitude and severity of the problem, there is a great need for the generation of evidence-based information to appropriately respond to the problem. Despite the abundance of many studies, the role of violence as an underlying factor in women's health during pregnancy and birth outcome remains an area where robust evidence is lacking. To serve the intervention programs, there is a need to generate information on the association between IPV and adverse neonatal outcome. In doing so, this study was aimed to contribute information which would be filling the existing information gap. The policy environment in the area of women's health and women's right are current efforts of the government taken to address the problem. The study of this kind can help the policy makers to look in to the grassroots level whether the existing policy issues are well understood by the public at large and to make further adjustments whenever needed. Furthermore, it may also serve as a base line data in identifying potential research areas for further studies. Nurses and other obstetric care providers working in maternal and child health centers as well as the community setting can use the finding of this study during prenatal education to inform couples about the risk of adverse birth outcomes in relation to intimate partner violence exposure. --- Methods A hospital-based unmatched case control study design was conducted in Tigray Regional state of Northern Ethiopia, from March to January 2017 in four randomly selected Zonal Public Hospitals. Tigray forms the northernmost reaches of the nine ethnic regions of Ethiopia and is located between 36 °and 40 °' East longitude. Its North-South extent spans 12 and a half degrees to 15 °north. It is bordered by Eritrea in the North, Sudan to the West, Amhara national state to the Southwest and Afar of Ethiopia to the East. The region covers 54,572 km 2 ranging from low-arid to highland areas. Tigray is subdivided into six administrative zones such as Central zone , Eastern zone , North Western zone , Southern zone , Western Zone , Mekelle . Tigray has an estimated population of 5,247,005 according to the 2009 EFY population estimation. Among those 2,660,002 are Females and 2,587,003 are Males [14]. The source and study populations for this study were all women who gave birth in selected Zonal Hospitals of Tigray, Ethiopia. All sampled women who gave birth in selected were also studied population for this study. Cases were all women who had adverse birth outcomes and Controls were all women who had a normal birth outcome in the selected zonal hospitals of Tigray, Ethiopia, during the study period. Data were collected by face to face interview method using a pre-tested structured questionnaire . It consisted of sociodemographic, obstetric, and experiences-of-violence related questions. Four female nurses and supervisors were recruited as interviewers and as supervisors respectively. Data collectors and supervisors were trained for two days on techniques of interviewing, the purpose of the study, importance of privacy, sensitivity of the issue, discipline and approach to the interviewees and confidentiality of the respondents. Adverse birth outcomes were measured by low birth weight, preterm birth. Low birth weight was defined as a live birth weighing < 2500 g. Preterm was defined as a neonate born before 37 completed weeks. The cut off points used for the birth outcomes were based on standards [17]. Intimate partner violence during pregnancy was assessed by asking women if she had experienced any act of physical, sexual or psychological abuse during index pregnancy by intimate partner. Controlling behaviors were defined as isolating a person from family and friends; monitoring their movements; and restricting access to financial resources, employment, education or medical care. Index pregnancy period, in this study refers to all trimesters of last pregnancy. The data were checked for completeness and inconsistencies, then entered using Epi-Info version 7 and cleaned and analyzed in SPSS version 21. Cross-tabulation was done to see the distribution of cases and controls. Descriptive statistics were used to characterize the sample and numerical data and was presented as mean + SD, median ± interquartile range, proportion or percentages. The binary logistic regression model was employed to examine the relationship or statistical association between the outcome variable and selected independent variables. All variables with a P value < 0.05 were included in the multivariable analysis. A multi-variable analysis was carried out to evaluate the association between intimate partner violence and adverse birth outcome after adjusting for confounding variables. Results were presented as adjusted odds ratios with 95% CI, which express the magnitude of the effect of each category on the outcome relative to the reference category. The significance level was set at P-value . Results were presented using tables and texts. Ethical clearance was obtained from the institutional review board of Aksum University, College of Health Science. Official permission was obtained from the Tigray regional health bureau. In addition, the ethical considerations were done by considering the personal and revealing nature of the study, which needed the required voluntary and informed consent to be obtained from the participants. Prior to administering the questionnaires, the objectives of the study were clearly explained to the participants and verbal consent was obtained. Confidentiality and anonymity were ensured throughout the execution of the study. --- Result --- Socio-demographic characteristics of respondents In this study, a total of 318 women's who had the adverse birth outcomes and 636 women's who had the normal birth outcome were included making a response rate of 100%. The mean age of mothers was 28.37 ± 6.25 years' ranging from 16 to 48 years. Seventy of cases and 138 controls were living in rural areas. Regarding marital status, 276 cases and 554 of controls were married. 209 of cases and 367 of controls were housewives by occupation and 43 cases and 85 of controls had not attended formal education. . --- Pregnancy and obstetric characteristics of mothers The median of parity for both cases and controls was 2 ± 2 ranges from 1 to 10 live births. Majority of the respondents, 632 controls and 311 cases had received ANC service at least once during the index pregnancy. More than one thirds, 281 of controls and 136 cases had > 3 number of pregnancies. . --- Types of intimate partner violence during pregnancy More than half, cases and one fourth of controls reported experiencing some form of IPV during the index pregnancy, 183 cases and 51 of controls reported experiencing some act of physical violence during their index pregnancy and one third of cases 103 and 26 of controls reported being slapped by their intimate partner as the most common type of physical violence during pregnancy. Less than one fourth, of the cases and 75 of the controls reported experiencing some act of sexual violence during pregnancy. Sixty-six of the cases reported having unwanted sexual intercourse, because they are scared of what their partner might do if they do not agree. This was the most common sexual violence followed by being forced to do something sexual that felt degrading or humiliating. 52 and 38 being Physically forced to have sexual intercourse. Similarly, the proportion of controls reported to be having unwanted sexual intercourse for fear of violence by their partner was 70 followed by being forced to do something sexual that felt degrading or humiliating 51 and 31 were physically forced to have sexual intercourse. Those women who had been exposed to intimate partner violence during pregnancy period had a pre-term and LBW infant. Of these,135 were as a result of exposure to physical violence. Some form of psychological violence was also experienced by 104 cases and 115 of controls. Insulting 3 show in a separate document). In addition, 129 cases and 116 of controls reported partner's controlling behavior during their index pregnancy. Partner's restriction of Health care 75, were the commonest form of partner's controlling behavior reported . --- The associations between intimate partner violence during pregnancy and adverse birth outcomes As can be noted from the result of the bivariate analysis, all of the 5 variables showed a significant association with the adverse birth outcome at 5% level of significance. All of them were included for further analysis. Intimate partner violence, sexual violence, physical violence, psychological violence, and controlling behaviors were entered in the multivariable logistic regression at 0.05 level of significance. A Multivariable logistic regression analysis was done by taking five variables in to account simultaneously to see significant association between intimate partner violence during pregnancy and adverse birth outcome. After an adjustment for age of women, marital status, occupation, area of residency, monthly income, educational status of women, ANC follow up, number of ANC visits, gravidity, and planned intention. The enter method regression was used after checking multicollinearity. Some of the variables which showed significant association with adverse birth outcomes in the bivariate analysis could not persist significantly in the multivariable analysis. These covariates were; psychological violence, sexual violence and controlling behavior. In the multivariable binary logistic regression analysis, only two variables had shown a significant effect on the birth outcome at 5% level of significance. Accordingly, it was found that the risk of PTB or LBW increased when the pregnant women were exposed to more than one type of violence. The odds of adverse birth outcome among those women had been exposed to more than one type of intimate partner violence during pregnancy were 3.12 times higher than those mothers who don't experience more than one type of violence during pregnancy [AOR = 3.119; 95% CI ]. Similarly, an association was also examined for subcategories of intimate partner violence . Physical violence during pregnancy was consistently associated with a significant increase in adverse birth outcome. It was observed that women who had been exposed to physical violence during pregnancy were 4.767 times at higher risk of having the adverse birth outcome as compared to those who had not [AOR = 4.767; 95% CI ]. . On the other hand, in this study sexual violence, psychological violence and husband controlling behavior during pregnancy were not found to be associated with a significant increase in adverse birth outcome . --- Discussion Intimate partner violence is an important public health, reproductive health, and social concern of the whole world. It could be a significant predictor of adverse outcomes for two individuals: The mother and her infant. Moreover, violence during pregnancy can have long-term consequences especially when it is under-recognized [15], This study was aimed to assess the association between In this study, more than one-third of the women had been exposed to intimate partner violence during their index pregnancy period. The partners controlling behavior, was the most common violence with a magnitude of about 25.7% followed by psychological violence 23.0% physical violence 19.5% and sexual violence 15.2% . This result is higher than the study results in Hosanna Town, Bale Zone, Moshi-Tanzania, South Carolina, Rwanda, Kenyan where 23, 25.8, 30.3, 35, 37% intimate partner violence were reported during index pregnancy period, respectively [18][19][20][21]. But, it is comparable with other systematic review of African studies where 2-57% of the mothers had been abused by their intimate partners during their pregnancy [16]. The variations in the reported IPV during pregnancy might be due to the differences in social beliefs on what constitutes IPV, tools and scales that were used for data collection and analyses and sample size and differences in study methodologies, parameters observed and the unwillingness of women to disclose. The finding of this study also showed that women exposed to all type of intimate partner violence during pregnancy were three times more likely to experience LBW and PTB [21] and a prospective cohort study from Tanzania LBW and preterm birth [17] which found that partner violence against pregnant women increased low birth weight and preterm birth. Other studies have also exhibited consistent results [18], Vietnam [19], Iran [20], USA [10,21,22], USA [13,16,23]. This study also showed that physical violence during pregnancy was consistently associated with a significant increase in adverse birth outcome. It was observed that, women who had been exposed to physical violence during pregnancy were five times more likely to experience LBW and PTB as compared to those who were not exposed to physical violence. This is consistent with prior study conducted in Vietnam and LBW [19],Tanzania PTB and LBW [17],USA [23,24] demonstrating that experiencing physical violence during pregnancy is associated with a multitude of adverse pregnancy outcomes including LBW, PTB, and neonatal death. One possible reason is physical IPV may lead to traumas causing premature rupture of membranes or cause abruption of the placenta and subsequently PTB and LBW. A slightly higher proportion of mothers of low birth weight and preterm infants reported having been abused sexually, psychologically and reported husband controlling behavior compared with controls, but the difference was not statistically significant. This agrees with the study conducted in Southeast Ethiopia which showed that sexually and psychologically are associated with adverse birth outcomes [25]. Perhaps one of the probable reasons of inconsistency with another study could be due to lack of a standard definition, regional variations in community awareness of violence during pregnancy and differences in study methodologies, setting, parameters observed and the unwillingness of women to disclose. --- Strength and limitation of the study This study is based on a large sample of pregnant women. Thus, it has sufficient power to detect statistically significant differences between abused and non-abused women with and without adverse birth outcome. Besides poor birth outcomes, victims of IPV and their children may suffer long-term negative health effects. Therefore, this study could be very crucial to establish a standardized comprehensive intervention that promotes birth outcomes for victims of IPV. Since the study was facility based and women who delivered at home were excluded in this study. Because of this reason, applicability of findings to the general population is uncertain. In addition, due to many ethical and social issues regarding physical and sexual violence, misreporting is conceivable. The sensitive nature of the topic and its proneness to response bias may lead to over-and under-reporting of the true extent of the abuse. --- Conclusion The findings of this study revealed that overall intimate partner violence and physical violence during pregnancy was associated with a significant increase in low birth weight and preterm birth. But neither husband controlling behavior nor sexual and psychological violence exposure yielded significant associations with adverse birth outcome in this study. Based on the study findings the following recommendations were forwarded to respective bodies. Health-care providers should be informed and aware of the possibility of violence as an underlying factor in women's ill-health during pregnancy and should focus discussions on healthy relationships across the lifespan, with a particular focus on pregnant mother. Health extension workers should provide primary prevention in the form of prenatal education to inform couples about the risk of adverse birth outcomes in relation to IPV exposure. The regional Health bureau should train health care providers on how to screen, counsel, treat, and follow up of abused women. Efforts to address maternal and newborn health need to include issues of violence against women. All health institution should Approach pregnancy care from a life course perspective necessitates that health care providers place greater emphasis on primary, preventive, pre-conceptional, and inter-conceptional care fundamental aspects of women's overall health. Development of interventions to prevent violence against women from happening in the first place, including those that promote gender equality and safe and responsible relationships is also a critical need. National programs targeting violence against women should therefore emphasize that violence exercised during pregnancy has very serious health implications. The study further demands for longitudinal research regarding the pathway through which violence may lead to risk of adverse birth outcomes. Lecturer at School of Nursing, College of Health Sciences and Comprehensive Specialized Referral, Axum University, Ethiopia. [email protected] GK holds MSc in Reproductive Health. GK is currently as clinical staff at College of Health Sciences and Comprehensive Specialized Referral Hospital, Axum University, Tigray, [email protected] AG holds MSc in Anatomy. AG is currently Lecturer at Department of Anatomy, College of Health Sciences and Comprehensive Specialized Referral Hospital, Axum University, Tigray, Ethiopia. [email protected] --- --- Additional file Additional file 1: Questionnaire for intimat partenr violence during pregnancy. Abbreviations AOR: Adjusted Odd Ratio; CI: Confidence interval; IPV: Intimate Partner Violence; IRB: Institution Review Board; SPSS: Statistical Package for Social Sciences; VAW: Violence against women Authors' contributions EB conceived and designed the study, analyzed the data and wrote the manuscript. DG and AG Data analysis, drafting of the manuscript and advising the whole research paper. DG was involved in the interpretation of the data and contributed to manuscript preparation. HB, GK involve in Tittle selection, Data analysis, drafting of the manuscript, approved the final manuscript. All authors read and approved the final manuscript. Authors' information EB holds MSc in Pediatric and Child Health Nursing. EB has 6 years' experience in Nursing Teaching and health research with particular emphasis on Child health and Maternal. EB is currently serving as the Lecturer at School of Nursing, College of Health Sciences and Comprehensive Specialized Referral, Axum University, Ethiopia. [email protected] DG holds MSc in Maternity and Reproductive Health Nursing. DG has 6 years' experience in Nursing Teaching and health research with particular emphasis on maternity and reproductive health nursing. DG is currently serving as the Lecturer at School of Nursing, College of Health Sciences and Comprehensive Specialized Referral, Axum University, Ethiopia. [email protected] HB holds MSc in Maternity and Reproductive Health Nursing. HB has 5 years' experience in Nursing Teaching and health research with particular emphasis on maternity and reproductive health nursing. DG is currently serving as the Ethics approval and consent to participate Ethical clearance was obtained from Institution Review Board of Aksum University, College of Health Science. Official permission was obtained from the Tigray regional health bureau for respective hospitals. In addition, the ethical considerations were done by considering the personal and revealing nature of the study, which required that voluntary, informed consent, using the consent form designed for this study, needed to be obtained from the participants. Prior to administering the questionnaires, the objectives of the study were clearly explained to the participants and verbal consent was obtained. Confidentiality and anonymity were ensured throughout the execution of the study. --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Intimate partner violence is a common phenomenon in Ethiopia families. About 81% of women believed that a husband is justified in beating his wife. About 30-60% of families were affected by their intimates. Women suffer physical, emotional, sexual and economic violence by their intimate partners. It often remains either for the sake of family secrecy, cultural norms or, due to fear, shame and community's reluctance on domestic affair and social stigma.The objective of this study is to examine the association between intimate partner violence during pregnancy and adverse birth outcomes. Methods: A hospital based unmatched case control study was conducted in four zonal hospitals of Tigray region. A total of 954 study participants (318 cases and 636 controls) were taken. Systematic sampling was used to select the cases and controls. Ethical clearance was obtained throughout the study period. Result: Out of 954 interviewed mothers, 389 (40.8%) had experienced intimate partner violence during their index pregnancy period. More than two third (68.6%) of cases had been exposed to intimate partner violence. Multivariable logistic regression analysis showed that, women exposed to intimate partner violence during pregnancy were three times more likely to experience low birth weight (AOR = 3.1; CI 95% [1.470,6.618]) and preterm birth (AOR = 2.5; CI 95% [2.198-2.957]). It was observed that women who had been exposed to physical violence during pregnancy were five times more likely to experience low birth weight (AOR = 4.767; CI 95% [2.515, 9.034]) and preterm birth (AOR = 5.3; CI 95%: 3.95-7.094).It was found that the risk of preterm birth and low birth weight was increased when the pregnant women were exposed to more than one type of intimate partner violence and physical violence during pregnancy. Therefore, Efforts to address maternal and newborn health need to include issues of violence against women.

et al., 2010) with structural equation modelling using data from the Canadian Longitudinal Study on Aging . We estimated associations between latent factors consisting of physical, psychosocial, environmental, financial, and cognitive attributes, and life space mobility for participants 65-85 years of age with age, sex and education as covariates. The model demonstrated good fit = 0.025 ). Physical, psychosocial, and cognitive health were positively associated with life space mobility. Being less afraid to walk after dark was also associated with greater mobility. Financial status influenced mobility through positive associations with psychosocial health and physical health. Higher education was related to better cognitive function and better financial status. Age was indirectly associated with life space mobility through its negative associations with financial status, cognition, and physical health. The same model can be used for males and females. The comprehensive mobility framework was verified with the large populationbased CLSA dataset. Continued use of the framework is supported as it accurately portrays the complexity of factors that influence older adults' life space mobility. Abstract citation ID: igad104.3050 --- CONTACT-FREE SPORTS ACTIVITIES DURING COVID-19: IMPACT ON SUBJECTIVE HEALTH AND STAMINA AMONG KOREAN OLDER ADULTS Gaeun Han, Juhyeong Lee, and Giyeon Kim, Chung-Ang University, Seoul, Republic of Korea Despite the importance of participation in sports activities among older adults, COVID-19 pandemic has limited access to sports facilities, which may threaten the physical and mental health of older adults. This study examines whether the relationship between age and subjective health and stamina is moderated by participation in contact-free sports activities among Korean older adults. A nationally representative sample of Korean older adults aged 65 or older and doing regular exercise was drawn from the 2021 National Survey on Sports for All. A moderation analysis was conducted by PROCESS macro using SPSS 26.0. Results showed that age was negatively associated with older adults' subjective health and subjective stamina , respectively. Participation in contact-free sports activities moderated the relationship between age and subjective health and subjective stamina , indicating that the effect of age on subjective health/stamina varies by participation in contact-free sports activities. However, the conditional effect of age on older adults' subjective health and stamina was significant only for those not participating in contact-free sports activities. The findings suggest that contact-free sports activities may mitigate the association between aging and physical decline in later life, especially during the pandemic and play a vital role in maintaining health and well-being of older adults. --- HOW ELDERLY PEOPLE INTERACT AFTER THEIR RETIREMENT WITH THE COVID-19 ERA IN JAPAN Fumihiko Yokota 1 , Mariko Nishikitani 2 , Gretchen Tucker 3 , and Dana Bradley 3 , 1. Kyushu University, Fukuoka, Fukuoka, Japan, 2. Kyushu University Hospital, Fukuoka, Fukuoka, Japan, 3. University of Maryland, Baltimore County, Baltimore, Maryland, United States Amid the COVID-19 pandemic, little is still known about how older Japanese people socialize after retirement. This paper aims to describe the dynamics of social interactions in post-retirement older adults during the COVID-19 pandemic. From January to March 2021, we interviewed 17 Japanese elderly people in Fukuoka and Ehime who were over 65 and have already retired. Face-to-face Interviews were conducted using a semi-structured questionnaire. After the initial transcripts were translated from Japanese to English, we checked the transcripts for accuracy and coded for analysis. The participant's mean age was 71 years old while their retirement's mean age was 60 years old. Only one participant had full retirement while the rest were partial retired which they continued to work as part-time workers either with new employers or with the same employers. All participants reported that their social interaction became estranged after retirement, and disrupted during the COVID-19 pandemic. However, participants communicated online and/or interacted face-to-face with neighboring people as a member of community association or volunteers, ex-work colleagues, old schoolmate, their children and/or grandchildren, friends with the same hobbies. Following factors that may affect the interactive behavior of Japanese older people were identified; Japan's healthcare policy and pension system, individual's socio-economic status, family structure and living arrangement, community's characteristics, individual's psychological, cognitive and health status, and individual's personality. Comparisons of social interactions between Japanese and US older adults will be important to find new knowledge for preventing social isolation. Abstract citation ID: igad104.3053 --- LEVEL OF OBSTACLES BETWEEN WORK AND CARE PROVISION AND LIFE SATISFACTION AMONG JAPANESE WORKING FAMILY CAREGIVERS Ayumi Honda 1 , Yin Liu 2 , Elizabeth Fauth 2 , and Sumihisa Honda 3 , 1. St Mary's College, Kurume, Fukuoka, Japan, 2. Utah State University, Logan, Utah, United States,3. Nagasaki University,Nagasaki,Nagasaki,Japan Objectives: This study aimed to examine whether facing obstacles between work and care provision is a risk factor for life satisfaction and explore whether it moderates the association between care burden and life satisfaction among Japanese working family caregivers. Methods: This cross-sectional study was conducted on 141 working family caregivers aged less than 65 years who were living with an older care recipient. We fit a multiple logistic regression model to examine the main and moderating effect of work/care obstacles on life satisfaction, in the context of care burdens. Results: Facing work/care obstacles had a main effect on life satisfaction among employed family caregivers. Furthermore, work/ care obstacles exacerbated the association between caregiver burden and life satisfaction. As for the family caregivers who did not experience work/care obstacles, the risk of poor life satisfaction did not differ regardless of number of caregiver burdens. In contrary, the family caregivers who experienced work/care obstacles and had 2 or more caregiver burdens had a poor life satisfaction compared with those who had 1 or less caregiver burden. Conclusion: These findings suggest that obstacles between work and family was a risk factor for poor life satisfaction for employed individuals in Japan caring for an older relative. Mitigating such obstacles may be important for job retention, given the growing number of older adults in Japan. Key words Facing obstacles between work and care provision, family caregiver, life satisfaction, well-being, work-life adaptation

1The healthcare system in India is struggling to meet the needs of the current population, and the rising aging population is likely to exacerbate this problem. Therefore, it is essential to plan and prepare for the future. Thus, using a geospatial approach, this study used data from the Census of India to investigate the distribution of older populations' access to improved health facilities across various cities in India. The study found wide variation in the proportion of the aging population across India, with cities in the northern, southern, and eastern parts of India having a higher percentage of older people. The study compared the distribution of older adult populations and health infrastructures, such as hospitals and medical staff, and found considerable regional variations in their availability. Smaller cities tend to have poorer health facilities than larger ones, despite having similar proportions of older populations. The study found that good health facilities were concentrated in specific pockets, particularly in metropolitan cities, while smaller cities lacked them. This infrastructure gap poses a significant challenge in achieving healthy aging in India. Population aging is a significant demographic trend that requires attention from policymakers, researchers, and healthcare professionals. This study highlights the need for improved health facilities in Indian cities, particularly smaller cities, to ensure the well-being and a better quality of life of older adults. By prioritizing the needs of the aging population, we can create a more equitable and sustainable healthcare system that meets the needs of all citizens.

Background International labor migration has become a crucial engine for economic development for many countries worldwide [1,2]. The growing economic aspirations of International Labor Migrants are driven by labor market demands of rapidly developing regions of the world. 'Source' countries for migrants from Asia, particularly female domestic maids include Sri Lanka, Philippines, Pakistan, Indonesia, India and Bangladesh [3]. 'Destination' countries consist of mainly the Gulf States, followed by emerging economies in Asia such as Singapore. ILMs from Sri Lanka has grown ten-fold during the past decade, with 90% employed in the Gulf, and 730 registered workers departing Sri Lanka each day [4]. In what was once a highly feminized labor force, today 49% percent of ILMs are women, and of these 86% are employed as domestic housemaids [4]. Remittances by migrant workers remained the single highest contributor to the Sri Lankan economy in 2012, with earnings expected to increase to 7bn USD by 2016 [5]. Despite these clear monetary benefits for the State, studies examining household savings and socio-economic status of returning Sri Lankan ILMs show mixed individual economic gains [6,7]. Due to this, most workers choose continuous cycles of re-migration to increase their savings. The 'balance sheet' of labor migration typically involves a trade-off between economic wellbeing and family proximity [8,9]. Through an economic lens, remittances may directly benefit a majority of poorer migrant households by increasing income. However, the reliance on remittance alone as a measure of poverty alleviation remains unclear. Its utility for human capital formation in migrant households through greater spending on health care, food and education also requires empirical exploration [7,10]. United Nations agencies have articulated the need for migration-related determinants of health to be explicitly included in the post-2015 Millennium Development Agenda through the UN general assembly's High Level Dialogue on International Migration and Development, and through the Global Migration Group [11]. The International Organization for Migration and the World Health Organization have led global efforts to stimulate member states to adopt migrant sensitive health systems and enable policies and practices to ensure realization of the right to health for migrant and mobile populations [12]. The UN Committee on the rights of the child have advocated for protection of child rights in the context of international migration, and the United Nations Children Fund has also articulated the scarcity of research on consequences of migration on child health and wellbeing worldwide [13]. --- Effects on child psychological well-being The adverse effects on the psychological well-being and development outcomes of children due to separation from a parent for extended periods has been characterized by a number of researchers [14][15][16][17]. However, such research examining transnational parental effects has focused on immigrant groups within industrialized countries rather than temporary labor migrant populations [18,19]. Only a few studies have examined the psychological impact on children of temporary labor migrant families from developing nations. A study by Graham and Jordan [20] measured psychological well-being among children of labor migrants under the age of 12. They showed that children of households in Indonesia and Thailand where mothers were labor migrants had poorer psychological well-being indices than children from non-migrant households [20]. A study of school children in Philippines by Battistella and Conaco [21] found little or no evidence that children of migrant families had greater psychological problems than children of non-migrants. Three studies from Sri Lanka examined health status of left-behind children utilizing standardized psychometric measures [22][23][24]. Results from all three indicated that absence of the mother was significantly associated with adverse behavioural problems in left-behind children. However, the following limitations were common in all the studies. First, they focused exclusively on male-headed households and did not include female-headed households. Considering that 52% of migrant workers are male [4], this left a significant gap in assessing health impact of children in such families. All studies used purposive samples obtained entirely from selected schools in an urbanized setting from a single district, and children of only one ethnic group were included. In order for policy makers and planners to make informed decisions on the impact of migration on childrens' well-being, more representative studies are needed from areas that supply large number of ILM's. --- Effects on child nutrition A number of studies have investigated the relationship between international labor migration and child malnutrition [25][26][27]. Remittances flowing from ILM's may affect child nutrition through two broad pathways. First, increased household income from the migrant parent sending back remittances may be used to enhance purchasing power for food and other goods. Secondly, by changing time and task allocations within the household, as the loss of a parent may reduce the time available to prepare food and/or to care for the child's nutritional needs. A review of literature identified only a few studies that examined nutritional outcomes in children left behind due to ILM. A study by Cameron and Lin [28] highlighted that the absence of a parent in migrant households had a negative effect on short-term child nutrition in Thailand. However, authors suggested increasing levels of household remittances may help lessen the negative effect on child nutrition. A nationally-representative longitudinal study by Nobels [29] in Mexico examined the effect of parental migration on child health by comparing children within households who are exposed to migration at critical periods of child development. Results suggested that parental migration negatively effects child height-forage, a long-term measure of child nutritional status and illness. The same pattern did not emerge from comparisons of children in non-migrant households. Frank and Hummer [26] who also studied Mexican migrant and non-migrant households found that membership in a migrant household reduced the risk of low birth weight, largely through the receipt of remittances. Though few in number, these studies highlight the complex relationship between temporary labor migration and child nutrition. With high rates of malnutrition in developing nations that are also major source countries for ILMs, and with the growing evidence base linking child nutritional deficiencies with mental health problems [30,31] exploring child nutrition remains an important policy area. --- Research objective Despite the political discourse on migration moving up the global development agenda [1,12], the public health implications for migrants and their families have received little attention. Analysts have also argued that Global Migration policy strategies have failed to recognize and adopt a family perspective [32,33]. A PLoS medicine series on Migration & Health in 2011 prompted public health attention and called for an evidence-based research agenda on health of migrants [34]. As described, there have been relatively few studies from countries, which 'supply' labor that considered the effects of international labor migration on children left-behind. This paper addresses the question of whether migrant children face an increased risk for adverse mental health and nutritional outcomes in Sri Lanka. --- Methods --- Study design and participants A cross-sectional survey was conducted in six districts of Sri Lanka with the highest number of outbound ILMs. The study population included the families of migrant workers , residing in one of the selected districts. The inclusion criteria for the study group were households where one or both parents were ILMs, who had their own or adopted child/children under 18 years of age living at the same residential address for a period of six months prior to the time of data collection. Children from families without a history of migration abroad were considered as the non-migrant 'comparative group'. The inclusion and exclusion criteria was adopted to ensure an accurate comparison of the effect of migration on left-behind families of ILMs is presented below. Our study included analysis of both adult and child members from these families, however, this paper only describes the child sample. We also undertook a comprehensive qualitative research study to explore the perceptions of left-behind migrant families, which has been published separately [35]. --- Definitions of participant categories and their inclusion and exclusion criteria Migrant Family: Inclusion criteria: a family where either one or both spouses have departed for employment abroad as a labour migrant for period of at least six months, have their own or adopted child/ children under 18 years of age, and the left-behind family been living at the same residence for a period of at least six months at the time of data collection. Exclusion Criteria: families in which the migrant worker was continuously absent in the preceding six months prior to leaving the country on assignment. Migrant Spouse: the spouse of the overseas-based migrant worker living in the migrant family household for at least six months. Child 'left-behind' : a child under 18 years who is living in the migrant family household for a period of at least last six months, and who's parent/parents are international labour migrant workers currently working abroad for a period of at least 6 months. Caregiver: a person living in the migrant family household who is not the biological mother/father, but who is responsible for taking on the burden of care for the left-behind child on a daily basis, for a period of at least six months. Care consists of activities such as; arranging daily schedules, preparing or ensuring access to meals, assisting the child's educational and social needs , washing clothes, looking after the child when he/she is sick, guardianship and representation to health and/or education authorities. Comparative Family: Inclusion criteria: A family where both parents are present, which neither spouse has a history of labour migration , have their own or adopted child/children under 18 years of age in the family unit. Exclusion criteria: one or both parents being absent from the same house for more than 60 days continuously or alternatively for the preceding six months Sampling A multi-stage random sampling method was used in the selection of ILM households. Grama Niladhari Divisions or 'village unit' is the smallest administrative population unit in Sri Lanka. Divisional Secretariat Divisions administrates a cluster of GNDs, and is responsible for coordinating social services in these villages [36]. A total of 41 DSDs were included in six districts with the highest number of ILMs . All GND in each 41 DSDs were listed and one GND was randomly selected from each DSD using a random number generation tool totaling 41 GNDs. A registry of all migrant households in each selected GND was created according to the information obtained from the Grama Niladhari , Public Health Midwife , and Samurdhi Niyamaka . Subsequently, ten migrant family households were selected randomly from each GND. Each randomly selected household was checked for inclusion and exclusion criteria, and to compensate for ineligible households, another household was selected randomly from the remaining list in the GND. The sample size was estimated using standard sampling power calculations [37]. A total of 410 migrant worker families and 410 families with no migration experience were included in study. Children between 12 to 17 years of age from migrant households were individually matched with children from the same school and class to find a comparative child from a non-migrant household within each GND. Children were then matched according to gender and age, and a list of children from families with no migration history were obtained from the attendance register available in the classroom with the responsible teacher. Similarly, pre-school children were also matched according to gender and age, from the list obtained from the PHM registry. Of the six districts, Colombo and Kandy have the vast majority of population living in densely populated urban centres with some peri-urban zones. Kurunegala and Gampaha districts have a population within a mix of urban, peri-urban and rural population catchments. Population in Puttalam district is concentrated in predominantly rural settings, with small urban centres. Rural populations are characterized by their dependence on agriculture for their livelihood, with an estimated 90% of the nation's poor living in rural settings. --- Standardized health instruments and outcome measures The study instruments were extensively validated using nominal group techniques and were previously used by authors in a large-scale national study on adult and child mental health in Sri Lanka [38]. The Questionnaire for socio-demographic data aimed at capturing basic social, economic, environmental and demographic indicators. Variables included gender, ethnicity, family size, employment type, educational status, home ownership status, household setting/conditions, household goods, income and expenditure. Measures such as migration history, frequency of ILM return from country of labour migration, household indebtedness, and frequency of remittance sent home were also captured. The questionnaire was administered to both the spouse/caregiver of the migrant family and to one adult member of the comparative non-migrant family. The Strengths and Difficulties Questionnaire is a reliable measure of the adjustment and psychopathology of children and adolescents. It indicates emotional symptoms, conduct problems, hyperactivity/inattention, peer relationship problems and pro-social behaviour. A computerised predictive algorithm generates "unlikely", "possible" or "probable" ratings for four broad categories of disorders, namely conduct disorder, emotional disorder, hyperactivity disorder, and any psychiatric disorder. The algorithm has been deemed to be sufficiently accurate and robust to be of practical value, and the level of chance-corrected agreement between SDQ prediction and independent clinical diagnosis considered substantial and highly significant [39]. The composite score from both 'abnormal' and 'borderline' scores were calculated to assess the risk potential in left-behind children to develop psychopathology. A 'borderline' or probable SDQ prediction for any given disorder correctly identified 81-91% of the children who definitely had that clinical diagnosis [39]. The three versions of the SDQ, for children, parents and teachers were used in the study. The instrument was adapted from original screening questionnaires [39], translated to both Sinhalese and Tamil languages and identical to one successfully used in a national child mental health survey in Sri Lanka [38]. The SDQ versions for teachers, parents, and for children between 6 to 17 years of age were administered to both migrant and comparative families. For each selected child or adolescent between the ages of 6 to 11 years, the child's parent/care-giver and their schoolteacher completed the SDQ, assisted by a trained field researcher. Children between the ages of 12 to 17 years also completed the SDQ and the composite score triangulated with results obtained by their parent and schoolteacher. The Check list for growth development and immunization was used to collect data from children under 5 years of age that were matched by age and gender from both migrant and comparative families. We focused on capturing nutritional status of young children aged 0 to 5 years, as these formative years are crucial for child growth and development [40]. Anthropometric data on child's growth, development milestones and immunization history were captured from individual Child Health Development Records issued by the Ministry of Health. PHM at the village level regularly recorded these measures at child health clinics, and records were also held by the parent/care-giver of the child. The CHDR registers the growth for children from birth to 5 years of age by body mass relative to age . Weight-for-age is commonly used for monitoring growth to assess changes in the magnitude of malnutrition over time. A child's 'underweight' status reflects both chronic and acute malnutrition . Child nutritional status and immunization history were recorded from CHDR records maintained by PHM from birth. --- Ethics, data collection & analysis The Ethics Review Committee of the Faculty of Medicine, University of Colombo, granted ethical approval. Data collection was conducted using a team of 22 trained field research assistants under the guidance of a psychiatrist, physician and two public health specialists. Permission to collect data was obtained from the regional education authorities, principals and teachers of each school. Participant information leaflets were sent to the parents through the selected school children. Later, the study was fully explained and written consent obtained from the parent or guardian. The study was also explained to all children and their assent was obtained. Data collection was supervised and managed by two dedicated project coordinators and a statistician. Double data entry and data analysis was conducted using SPSS version 17 and STATA. Statistical analysis included descriptive analysis to determine demographic information and frequency of the exposure and outcome variables. Chi-square tests were performed to ascertain differences between migrant and comparative children. We used standard multivariable linear regression models for continuous outcomes and multivariable logistic regression models for dichotomous outcomes. Univariable and multivariable analyses were used to investigate psychological outcomes of children of migrant vs. non-migrant families. Multivariable models were adjusted for child age and gender. --- Results --- Socio-demographic characteristics A total 410 children from migrant families were matched with 410 children from comparative households . A response rate 94% was achieved from the total of 820 families that were recruited for the study . A similar gender disaggregation profile was observed in children of both migrant and non-migrant families . Vaccination status according to the Ministry of Health guidelines of the expanded program in immunization schedule showed a high level of coverage, with the migrant children having a 95.4% completion rate. --- Nutritional status of children under 5 years of age The measure of 'underweight' contained in the CHDR reflects both chronic and acute malnutrition, and is measured by weight relative to age. The proportion of children that were in normal weight range in the migrant households was 38.2%, while the frequency in comparative households was higher at 46.9% . Over a quarter of the left-behind children were underweight or severely underweight, compared to 17.7% of non-migrant children. However these effects were not statistically significant . --- Mental health burden of children The dimensions of child psychopathology of children 6 to 17 years of age was measured through the Strengths and Difficulties scale, and predicted children of migrant families would experience greater emotional problems following parent-child separation than non-migrants. The burden of emotional problems [10.9%, 95%CI: 7.2 -14.6, p < 0.05] and hyperactivity disorders [8%, 95%CI: 4.7-11.2, p < 0.005] is highest in children from migrant families than from children in comparative families . Two in every five left-behind children had clinically relevant child psychiatric disorders [95% CI: 37.4-49.2, p < 0.05]. Whilst child conduct problems were higher in left-behind children than those in non-migrant households , these were not statistically significant . The mental health status of the parent/caregiver of a child was strongly associated with child psychopathology. This effect was observed in both migrant [Adjusted OR 1.63 ] and non-migrant families [Adjusted OR 2.44 , p < 0.005]. --- Migration and health related factors of parents and caregivers The ethnic profile of the study sample closely matched national population ratios from the 2001 national population census, with 74.5% of migrant families and 78.2% of non-migrant groups being of Sinhalese ethnicity [41]. The mean age of parents of left-behind children was 37.9 years, with the majority of families living within rural settings . There were twice as many fathers taking the role as the primary carer of left-behind children in the migrant family group than of the comparative non-migrant group . The results show the proportion widowed/divorced parent to be greater in the migrant family group than in comparative families . Typology of employment of the migrant worker was assessed according to the Sri Lanka Bureau of Foreign Employment classification of occupations [4]. The majority belonged to the low-skilled occupation classification of 'manual laborers' and 'domestic housemaids' . More than half of migrant workers were reported by their spouses as having not returned to Sri Lanka since going abroad for work. Only 42.9% of the spouses of migrant workers reported receiving some form of monthly monetary remittances. General health was perceived to be three fold poorer in parents of migrant children than compared to the non-migrant families , p < 0.001. There were also nearly twice as many migrant parents currently diagnosed with illness than comparative parents from non-migrant households p < 0.001. Overall prevalence of common mental disorders in adults was higher in left-behind parents/caregivers of migrant children [19.2% ] than the non-migrant parent group [9.1% ]. Prevalence of depression was doubled in the migrant group , compared with non-migrant parents . Prevalence of somatoform disorder and anxiety disorder was marginally higher in spouses of migrant families than that of non-migrant counterparts . Mental health outcome associations with demographic, economic, migration-related and health-related factors Table 4 describes the unadjusted and adjusted associations between the primary SDQ outcome with selected child and parental socio-economic and health indicators. In the adjusted analyses, significant associations were observed between child psychopathological outcomes and gender of child, parent/caregiver's educational attainment and their mental health status. The adjusted odds ratio showed presentation of any child psychiatric diagnosis is 40% less likely in female children as compared to male children in left-behind families [OR 0.60 , p < 0.05]. A similar association was observed in children from non-migrant families [OR 0.54 , p < 0.05]. Educational status and employment status of the parents/giver of the child also influenced child psychopathological outcomes. The adjusted odds ratio of having any psychiatric diagnosis was 2.67 times more likely in left-behind children whose parents had not attended school [OR 2.67 , p < 0.05]. In children from migrant families whose left-behind parents were unemployed, the likelihood of having any psychiatric diagnosis was 1.13 times higher than those employed [OR 1.13 ]. However, this result was observed only before adjustment for child age and gender. --- Discussion This study addresses the question of whether left-behind children of migrant workers are at increased risk for mental health problems and adverse nutritional status. Whilst observational studies cannot determine causality, the evidence suggests overall negative associations at the intersection of labor migration and child mental health, but a weak association with nutritional status. --- Effects on child mental health and wellbeing A number of researchers have theorized that migration of a parent for extended periods may transform family relationships and functioning [42,43]. For left-behind children, the main concerns centre on how separation from parents affects their social, behavioural and psychological development. In our study, two in every five left-behind children were shown to have clinically relevant child psychiatric disorders. These results suggest that socio-emotional maladjustment and behavioural problems may occur among left-behind children in the absence of a parent. Findings from this nationally representative study corroborates with findings from smaller scale studies conducted in Sri Lanka that showed adverse behavioural outcomes, emotional and conduct disorders in school aged children of female migrant workers [22][23][24]. The crucial finding was that the psychological impact on families was also observed in families where the father is the overseas migrant worker. Qualitative studies have suggested that it is more challenging to achieve intimacy with children for migrant fathers than mothers [19,44]. Our results also revealed that male left-behind children were more vulnerable to psychopathology. This finding may need further exploration to specifically ascertain gender dimensions of transnational parenting, and measure child resiliency. In the adjusted analyses, significant associations were observed between child psychopathological outcomes and the gender of the child, parental education and their mental health status. Studies from other Asian countries show mixed patterns of psychological well-being of left-behind children. A study by Graham and Jordan [20] revealed that children of migrant fathers in Indonesia and Thailand are more likely to have poorer scores of psychological wellbeing than children in non-migrant households. However, this finding was not replicated for children of migrant households in the Philippines or Vietnam. The authors argued for more contextualized understandings in light of results showing divergent mental health outcomes. A study of school children in Philippines by Battistella and Conaco [21] found little evidence that children of migrant families had greater psychological problems than children of non-migrants. A multi-site study in the Philippines concluded that Filipino children in transnational families were found to be 'no less anxious or lonely' than their counterparts in nonmigrant families [45]. Acceptance by communities of the 'normalcy' of transnational migrant families and for transnational parenting may act as a determinant to reduce vulnerability and enable resiliency of the left-behind child [46]. The anxieties of a child arising from parental separation may be 'less traumatic' if the migration experience is shared collectively and is normalized within social structures [46]. It is hypothesized that as international out-migration becomes more normative within high out-migration communities, certain child behavioral problems may decrease [20], with children developing along adaptive trajectories [47]. Since resilience is characterized as consisting of multiple dimensions that may change over time [48], vulnerability may lie upon a continuum that could be exacerbated by extended periods in the 'left-behind experience' of a child. Further research, which identifies resilience factors in left-behind children, will therefore be useful. The Philippines has been recognized for its pro-active policy and program efforts in protecting the rights of its labour migrants and enabling a culture of support to families through a network of civil society and nongovernmental organizations [49]. These institutional programs and informal support schemes may also serve to directly and indirectly support the normalization of migration within the social fabric. More research is needed to establish the process and extent to which such programs enable a safe and dignified labour migration experience and how they may be protective for left-behind children. --- Effects on child nutrition Over a quarter of children aged 6-59 months of migrant households were found to be underweight or severely underweight. The findings of our study revealed that the comparative non-migrant child groups also have a high risk of being underweight . These finding are consistent with the underlying nutritional trend in Sri Lankan children that shows an overall prevalence of underweight children in 2009 to be 22.1% [50]. The few studies that describe nutritional outcomes in children left-behind have shown mixed effects; with Gibson and Nobles finding an overall negative effect [25,29], while Frank and Hummer [26] attributing a positive effect on child nutrition, especially with high levels of household remittances. The nutritional status of left-behind children may be influenced by a complex inter-play of underlying social determinants and cultural gradients that extend beyond the effects of enhancing purchasing power of food due to remittance income, child care-demands and food-preparation dynamics at household level. Further research is required not only to 'unpack' these factors and their associated interrelationships, but also to explore the nutritional impact on child mental health and development [31,32]. --- Strengths, limitations and future research directions A major strength of the study is its representativeness. Previous small scale studies focussed on only maleheaded migrant households, derived from a single ethnic group , and from an urban setting within a capital city . Our sample was derived from a true cross-section of the left-behind families of migrant workers in Sri Lanka. The generalizability of our findings is therefore enhanced. Our sample was also reflective of the true pattern of work categories published by the SLFBE data: seventy-five percent of labour migrants worked in the 'unskilled' labour sector, with professional categories comprising of less than ten-percent of departures. Our study primarily focused on child psychopathology, however, resilience and protective factors were not adequately explored. Identifying such enabling factors and resilience trajectories in left-behind children is crucial for formulating policies and programs to effectively manage migration and address health and social impact. Whilst this study provides an insight into how migration effects health status of left-behind children, further research is needed to explore how intra-household power dynamics, transnational parenting, relationship outcomes, and whether male versus female headed households have an effect on child health outcomes. Research is needed to assess how factors such as the duration and frequency of an often cyclical pattern of migration affects health outcomes; how household remittances are actually spent to promote child development outcomes; children's own experiences/expectations; abuse and violence within migrant families; and, how left-behind families access support services at community level. Cross-sectional studies may only suggest but not determine causality. Prospective cohort and longitudinal studies are needed to assess if children left-behind truly recover from the experience of parental migration. The re-integration of migrant parents after a long-term absence from child may cause problems due to acculturation issues, family conflicts and re-establishment of livelihoods [51]. The impact of parent-child separation among leftbehind children may also need comparison of mental health conditions before and after the separation. From a socio-ecological perspective, those 'left-behind' may not only effect migrant children and families but also extend to entire communities [52]. Longitudinal studies are needed to establish if migration actually leads to enhancing health outcomes and aids meaningful social and economic prosperity. --- Conclusions The findings from this study contribute to an evidencebased approach to developing Sri Lanka's Migration Health policy and program processors. In our study, two in every five left-behind children were shown to have mental disorders, with a significant burden of socioemotional maladjustment and behavioural problems. Concerns centre on how separation from parents may effect nutritional, behavioural and psychological development of left-behind children. Community programs to strengthen the capacity of relevant government workers such as public health midwifes , child protection officers, school counsellors and foreign employment agency welfare officers to identify and address social, health and nutrition issues of families left behind are needed. Programs may involve undertaking mapping and vulnerability assessments of migrant families through a coordinated network of such village level workers; development of case management or care plans for left-behind children using community participatory approaches; providing awareness and information to prospective migrant families; and providing guidance for primary caregivers of left-behind children. As contractual labour migration to places like the Middle East remain a pervasive phenomenon, the impact on children left-behind leaves many unanswered questions. The consequences of long-term migration on family relationship structures, parenting and health vulnerabilities have complex associations that require further longitudinal analysis. The World Health Assembly resolution on health of migrants promotes a 'safe, dignified and healthy migration' process for the benefit of both migrants and their families [53]. Though further research is required, this study shows a need to address the social determinants of health affecting migrant families. The finding that almost one-third of the sample were single parent families, that child psychopathology scores were highest in these leftbehind families, a growing reliance on elderly care-givers and impacts of trans-national parenting pose complex challenges for policy makers, and raises debate at the nexus of rights, remittances and responsibilities for both State and ILM. The high levels of malnutrition in many labour sending countries within the developing world and the complex interplay between migrant remittances and child nutrition also form an important yet unexplored policy area. Balancing human rights discourses , in the context of social and health impact to both families and remittance dependent economies form formidable policy challenges for governments seeking to 'manage' migration and development. --- Competing interests The authors declare that they have no competing interests. The authors alone are responsible for the content and writing of the paper. Authors' contributions KW, CS, AS, SS, SP and PV conceived the study and were involved in study design. CS, SS, AA, KJ, BJ and SW contributed to the coordination and supervision of field teams and data collection and management. KW, CS, AS, SS and GP analysed the data and contributed to interpretation of data. KW and CS conceived the paper and KW wrote the first draft. KW and CS finalized the manuscript. All authors read, critiqued and approved the final manuscript. We would also like to thank the reviewers for their valuable comments in improving the manuscript.

Background: One-in-ten Sri Lankans are employed abroad as International Labor Migrants (ILM), mainly as domestic maids or low-skilled laborers. Little is known about the impact their migration has on the health status of the children they 'leave behind'. This national study explored associations between the health status of 'left-behind' children of ILM's with those from comparative non-migrant families. Methods: A cross-sectional study design with multi-stage random sampling was used to survey a total of 820 children matched for both age and sex. Socio-demographic and health status data were derived using standardized pre-validated instruments. Univariate and multivariate analyses were used to estimate the differences in mental health outcomes between children of migrant vs. non-migrant families. Results: Two in every five left-behind children were shown to have mental disorders [95%CI: 37.4-49.2, p < 0.05], suggesting that socio-emotional maladjustment and behavioural problems may occur in absence of a parent in left-behind children. Male left-behind children were more vulnerable to psychopathology. In the adjusted analyses, significant associations between child psychopathological outcomes, child gender and parent's mental health status were observed. Over a quarter (30%) of the left-behind children aged 6-59 months were 'underweight or severely underweight' compared to 17.7% of non-migrant children. Conclusions: Findings provide evidence on health consequences for children of migrant worker families in a country experiencing heavy out-migration of labour, where remittances from ILM's remain as the single highest contributor to the economy. These findings may be relevant for other labour 'sending countries' in Asia relying on contractual labor migration for economic gain. Further studies are needed to assess longitudinal health impacts on the children left-behind.

Introduction --- A n optimal diet during adolescence is important to support normal growth and development. 1 Dietary habits developed in adolescence may contribute to form adult dietary habits. Both early circumstances and adult life circumstances may in turn influence disease risk. 2 On the population level, nutrition plays an important role in the development of many diseases, in particular noncommunicable chronic diseases. 3,4 Morbidity and mortality from such chronic diseases, like cardiovascular diseases, some cancers, type 2 diabetes and obesity, have higher prevalence and incidence in groups of lower socio-economic position. [5][6][7] A recent WHO report 8 recommended, among other things, a diet with less saturated fat, sugar and salt and an abundance of fruits and vegetables to combat non-communicable chronic diseases. Since fruits and vegetables contribute to cardiovascular health due to the variety of phytonutrients, potassium and fibre they contain, 8 an intake of at least 400 g of fruit and vegetables a day are recommended to reduce the risk of coronary heart disease, stroke and high blood pressure. A reduced intake of sugar-sweetened drinks among children has also been shown to be important in weight management. 8,9 Social inequalities in health can be understood as a result of the prolonged processes that start several years before the effects are displayed. 2,10 Socio-economic position can affect health at any point, from birth or even during foetal life until death, and the effect of social inequalities may accumulate over time. 11 Also, there may be critical periods when the impact of socio-economic position has greater effect on health and lifestyle. Adolescence as a critical period for socio-economic inequalities in health has been challenged by studies who found almost no gradients in health among adolescents, which suggests that schooling and peer influences may lead to greater homogenization. 12 However, socio-economic inequalities in adolescents' lifestyle factors, such as dietary habits, may contribute to inequalities in health and disease in later life. In particular, this could be true for morbidity and mortality from non-communicable chronic diseases. 10,11 The main objective of this study was to examine associations between selected indicators of adolescents' health-related dietary habits and parental socio-economic position . We also wanted to study if using indicators of socio-economic position determined by mother's and father's position separately would give different results. --- Methods --- The HUNT study The county of Nord-Trøndelag in Norway has a stable and homogenous population with 127 000 inhabitants. The sex and age distribution is similar to Norway as a whole. The same is true for geography, industry and for sources of income and economy. The county lacks large cities, and the level of average income is somewhat lower than the average of Norway. 13 In 1995-97, all inhabitants aged 13 years and older were invited to the Nord-Trøndelag Health Study . Students in junior high schools and high schools, 13-19 years old, were invited to the adolescent part of HUNT, Young-HUNT. The students filled in questionnaires and were screened for a number of health measures. Information on the adolescents' health-related dietary habits from Young-HUNT was merged with information on parental socio-economic position from the adult part of HUNT 2 and register data from Statistics Norway via the Norwegian Family Registry. The present study included 8817 adolescents, accounting for 89% of students in junior high schools and high schools in the county, and their parents. Information on parental social class, Erikson Goldthorpe and Portocarero , 14 was available from parental participation and self reporting of occupational categories in HUNT 2. This gave a larger proportion of missing data due to parents not participating in the HUNT 2 study and incompletely filled in questionnaires. Information on parental educational level and income was available from the national register data, and therefore also for parents not participating in the HUNT 2 study. All participants and parents of children under the age of 16 years signed a written consent to take part in the study. The study was approved by the Regional Committee for Medical Research Ethics and the Norwegian Data Inspectorate Board. --- Measuring health-related dietary habits Adolescents' health-related dietary habits were measured using questionnaires with the question: 'How often do you drink or eat the things listed below?' We studied the intake of candy, chocolate and other sweets , cola, soda or other soft drinks , fruit and vegetables. The answers were reclassified into daily consumption and not daily consumption . We selected the four dietary variables listed above because they could clearly be categorized as healthy or unhealthy. Other dietary variables that could also have been categorized as healthy or unhealthy were not used in these analyses because there was little variation in the answer categories. The health-related dietary variables in Young-HUNT were the same as in the well established cross-national WHO study 15 on Health Behaviour of Schoolaged Children . 16 A Belgian study indicates sufficient reliability and validity of the HBSC food-frequency questionnaire for correlation analyses. 17 Beginning around the age of 10, the cognitive processes of children and adolescents become more similar to those of adults, 17,18 which further supports the use of food-frequency questionnaires in the relevant age group . --- Parental socio-economic position Data on parental education and income was made available by Statistics Norway and EGP social class information from parental participation and self-reporting of occupational categories in HUNT 2. Education was measured as the highest level of education attained. We reclassified the educational data into three levels: primary education , secondary education and tertiary education . Data on income was based on pensionable income in 1995. We calculated parental income in quartiles by mother's income, father's income and by adding together the income of the mother and the father. The EGP social class scheme was approximated with a reclassification of 10 original self reported occupational categories. 13 A comparison of this approximation and a standard procedure based on separate occupational codes has shown the applicability of this reclassification. 19 The respondents were asked to classify their last held or present occupation. We merged class I and II into upper class, III and IV into middle class and V+VI and VII into lower class. Adolescents with parents who reported that they had 'never been economically active' were treated as missing for EGP social class. --- Statistics The prevalence was adjusted for age by direct standardization. The standard population consisted of girls and boys 13-19 years old as of 1 January 1999 in the Nord-Trøndelag county. The odds ratios were obtained by logistic regression. Age was adjusted by including a continuous variable representing age in years. The analyses were carried out separately for girls and boys and by maternal and paternal socio-economic position. All statistical analyses were performed using the statistical software SPSS for Windows, version 15.0. --- Results Out of the 8817 adolescents who were eligible for analyses, there were 4384 girls and 4433 boys. The results showed that the girls tended to consume more fruit and vegetables and less candy and soft drinks than the boys . The gender difference was particularly evident regarding drinking soft drinks daily . Table 1 shows prevalence and prevalence ORs in the girls' health-related dietary habits by maternal and paternal level of education. Higher levels of parental education were consistently associated with healthier food habits: more frequent intake of fruit and vegetables and less frequent intake of candy and soft drinks. This association was more pronounced when maternal educational level was measured. Girls with the least educated mothers had a prevalence OR of 2.5 for drinking soft drinks daily and 0.6 for eating vegetables daily when compared with girls with the most educated mothers. The educational gradient was less pronounced in daily intake of candy in comparison with soft drinks, fruit and vegetables. Table 2 shows prevalence and prevalence ORs in the boys' health-related dietary habits by maternal and paternal level of education. The trend of the boys was similar to that of the girls, although the inequalities were somewhat less pronounced among the boys. Boys with the least educated mothers had a prevalence OR of 1.9 for drinking soft drinks daily and 0.6 for eating vegetables daily when compared to boys with the most educated mothers. Table 3 shows prevalence and prevalence ORs in the girls' health-related dietary habits by maternal and paternal EGP social class. Higher EGP parental social class was associated with more frequent intake of fruit and vegetables and less frequent intake of soft drinks. There seemed to be no clear gradient by maternal or paternal EGP social class for the reporting of eating candy daily. Table 4 shows prevalence and prevalence ORs in the boys' health-related dietary habits by maternal and paternal EGP social class. Higher parental EGP social class was associated with a more frequent consumption of fruit and vegetables. However, the gradient by maternal and paternal EGP social class was indistinct for daily consumption of candy and soft drinks among the boys. The exception was in drinking soft drinks daily by paternal EGP social class, where the boys with fathers in EGP social class III + IV had a prevalence odds ratio of 1.3 and boys with fathers in EGP social class V + VI + VII had a prevalence odds ratio of 1.4 compared with boys with fathers in EGP social class I + II. Also by EGP social class, we found that the inequalities were somewhat less pronounced among boys compared to girls. We found virtually no income gradients for fruit and vegetables by all three income measures . --- Discussion We found a clear association between parental socio-economic position and adolescents' health-related dietary habits. However, income showed virtually no gradients. Parental educational level, in particular the mothers, showed the highest impact on the adolescents' health-related dietary habits. The inequalities in education and EGP social class were somewhat more pronounced in the girls than in the boys. In general, girls tended to eat fruit and vegetables more frequently and consume candy and soft drinks less frequently than the boys. Socio-economic inequalities in health in children and adults are well established, but in adolescents this correlation has been debated. West et al. 12 found almost no gradients in health among adolescents in the West of Scotland and suggest an equalization in youth due to homogenization through schooling and peer influences. However, previous studies have shown a fairly consistent pattern where adolescents from families in a high socio-economic position eat more fruit and vegetables than adolescents from families in a lower socio-economic position. [20][21][22][23][24] This pattern was observed within a large number of operationalizations of socio-economic position, also in our data. However, parental income showed virtually no gradients in adolescents' healthrelated dietary habits. It may be that education and social class are more stably correlated to healthy eating habits than income. Education could provide important socio-economic influence on health-related behaviour as it may increase a sense of personal control 11,25 and ability to grasp and utilize health-related information. 26 We found that maternal educational level showed the highest impact on the adolescents' health-related dietary habits. It is likely that women, wives and mothers tend to have a stronger influence on the family's health-related behaviours by providing meals, spending more time in the household and organizing the household. A woman's educational level may influence the household more than a man's educational level: it may affect men's health-related behaviours 27 and may have the most influence on dietary habits. 28 Our finding of a strong association between maternal educational level and adolescents' dietary habits could be a result of such circumstances; since wives influence health behaviours of their husbands, we can assume this influence extends to their children and other family members. More than half of the adolescents did not meet the recommended intake of 400 g of fruit and vegetables a day, 8 as they did not eat fruit and/or vegetables daily. We found that the girls ate healthier and more in line with dietary guidelines than the boys. Both of these findings are in line with other studies on food consumption in adolescents. 1,20,21,[29][30][31] The strength of this study is that it covers a population of 8817 adolescents, with a total participation rate of 89%. We also had almost complete register data on the adolescents' parental educational level and income, measured by both the mother and the father. However, there were more missing values in the data on parental EGP social class for three reasons: some parents chose not to participate in the HUNT 2 study, some did not complete their questionnaires and some reported never having been economically active. Since missing values could have lead to biased estimates, we analysed the association between missing values due to missing data on parental EGP social class and parental educational level. We found that the prevalence of missing values was significantly larger with a lower parental educational level. This may have introduced an underestimation of differences in the adolescents' health-related dietary habits by parental EGP social class. This finding coincides with a study on the socioeconomic patterning of survey participation and non-response error. 32 The generalizability from Nord-Trøndelag to Norway has been considered good because the region has representative geography, demography and average socio-economic mortality. 33 However, the county lacks large cities, and the level of average income is somewhat lower than the average of Norway as a whole. As big cities usually demonstrate greater inequalities than rural areas, Nord-Trøndelag may be more egalitarian than Norway as a whole, 13 in which case social inequalities may be underestimated. On the other hand, one might think that accessibility to large supermarkets, which offer a large range of foods and fresh foods at low prices, may be more restricted in rural areas. Discussions in the literature suggest that access to shops, as well as quality and price, play an important role for the consumption of fruit and vegetables. 34 There is no evidence to suggest that the food distribution is more restricted in Nord-Trøndelag than elsewhere. Furthermore, recent studies from the Netherlands, the UK and Australia have shown that food shopping environment may not contribute to health-related dietary habits and socio-economic inequalities in food choice. [34][35][36] There have been some nutritional changes since the data were collected. The use of sugar has declined over the last decade while the consumption of fruit and vegetables has increased. 37 However, a satisfactory consumption level of these foods has not been reached yet. The sales of soft drinks are still very high, and the consumption of candy has increased. From 2007, free fruit and vegetables are offered to pupils in junior high schools nationwide. Providing this for free for all pupils could contribute to reducing social inequalities in fruit and vegetable consumption, since charges seem to increase social inequalities in fruit and vegetable intake. 38 Furthermore, the Norwegian government increased charges on sweetened beverages from 2009 to promote a reduction in the consumption. Based on the assumption that socio-economic position is ascribed rather than achieved among adolescents, researchers have used indicators based on parental occupation, education and income. 12 These indicators of socio-economic position are used to classify individuals in groups of similar status or prestige, power, knowledge and resources. 39 Each indicator has a unique contribution in capturing aspects of socioeconomic position, even though the indicators typically are shown to be weakly to moderately correlated. 40 By using more than one measure of socio-economic position separately, we have not taken into account the covariance between different measures. However, it is important to describe observed behavioural patterns in different concrete socio-economic groups in the population to use in the development of new hypotheses of causal mechanisms, in further and more analytical studies as a basis for public health strategies. As part of a strategy to prevent many diseases, particularly non-communicable chronic diseases, we should aim at initiatives to improve adolescents' dietary habits. Special considerations should be given to groups in lower socioeconomic positions and boys. A more analytical approach is needed to investigate why higher levels of socio-economic Dietary habits by socio-economic position position and higher levels of education seem to be associated with healthy dietary habits among adolescents. Regardless of such explanations, the social patterning of adolescents' eating habits clearly have public health implications. --- Supplementary data Supplementary data are available at EURPUB online. Conflicts of interest: None declared. --- Key points This population-based study examines health-related dietary habits in adolescents by parental education, social class and income stratified by gender and by maternal and paternal socio-economic position. Though the girls ate healthier and more in line with dietary guidelines, more than half of both girls and boys did not meet WHO recommendations on intake of fruit and vegetables. We found that higher parental socio-economic position was associated with more healthy dietary habits among adolescents, but there was virtually no gradient by income. Parental educational level, in particular the mother's education level, showed the highest impact on adolescents' health-related dietary habits. Any public health interventions with regard to dietary habits in adolescents should recognize this social patterning.

Background: Nutrition is among the important determinants of diseases, and the social patterning of early eating habits may offer keys to prevention. We studied associations between selected indicators of adolescents' health-related dietary habits (daily intake of candy, soft drinks, fruit and vegetables) and parental socio-economic position (education, social class and income). Methods: The material consisted of participants in the adolescent part (Young-HUNT) of the Nord-Trøndelag Health Study during the period 1995-97, 8817 girls and boys aged 13-19 years (89% of all students in junior high schools and high schools in a Norwegian county). Data on parental socio-economic position was available from the adult part of HUNT and Statistics Norway. Cross-sectional data analyses were performed using cross-tables and binary logistic regression. Results: Of the indicators of socioeconomic position used, the parent's educational level, in particular the mother's education, showed the highest impact on adolescents' health-related dietary habits. Girls with the least educated mothers had a prevalence odds ratio of 2.5 (1.8-3.3) for drinking soft drinks daily and 0.6 (0.5-0.8) for eating vegetables daily as compared to girls with the most educated mothers. The corresponding numbers for boys were 1.9 (1.5-2.4) and 0.6 (0.5-0.8). Parental social class also showed gradients in adolescents' health-related dietary habits, but there was virtually no gradient by income. Conclusion: Higher levels of parental education, in particular the mother's education, are clearly associated with healthier dietary habits among adolescents. This social patterning should be recognized in public health interventions.

Introduction Indonesia, the world's fourth-most populous country, has experienced a significant increase in its aging population each year. As of 2019, there were 25 million older people aged 60 and over in the country, accounting for 9.6% of the total population . The number of older people in Indonesia continued to rise in 2020, with 26 million individuals comprising 9.92% of the population . Recent statistics show that the number of older Indonesians has reached 29.3 million, making up 10.82% of the population . These statistics demonstrate a clear trend of population aging in Indonesia, which has significant implications for public policy and social programs aimed at supporting the needs of older individuals. The public higher-education sector in Indonesia is also affected by the country's aging population, with a significant increase in the number of older academic members each year. Based on government data, the percentage of older academic staff in public higher-education institutions was 27.16% in 2018 . However, this percentage slightly decreased in 2019 to 27.13%, or 21,712 older academic staff of the total number of academic staff in Indonesian public higher-education institutions, which was reported to be 80,023 . Maintaining health is one of the most pressing issues that older people experience, as emphasized by the WHO . A study by scholars on the theory of "active aging" , found that participation in various activities is a key factor in maintaining older people's health and well-being; older adults who participated in social activities experienced an improvement in their quality of life during the aging process . This finding has been supported by another scholar, who highlighted the benefits of social activities for the health of older people . Older people's participation is observed in different domains, such as work opportunities , social activities , and political engagement . Both scholars and officials at WHO emphasize the importance of participation in various activities. However, older individuals are often susceptible to certain forms of social withdrawal, such as shyness, avoidance, and unsociability . These social-withdrawal characteristics among older people can have a significant impact on data collection for research and policy formulation in public universities. This can lead to lower response rates and an incomplete understanding of older adults' needs and perspectives, as we highlight in this report. Specifically, this study aims to investigate the effects of social withdrawal on data collection and the process of formulating policy concerning older adults at public universities. --- Older Indonesian Academic Staff According to Indonesian Law 13/1998 on the Welfare of Older People, individuals in Indonesia are considered "older people" when they reach the age of 60 . However, most Indonesians begin retiring from their official jobs before they turn 60. State business and private-sector workers begin retiring at age 55, while government workers start at age 58 . But certain occupations mandate retirement at age 60 or later, including academic staff in higher education who retire at the age of 65 or at 70, if they have been promoted to full professor . Regardless of gender, older academic staff members have the same responsibilities and obligations as their younger colleagues. These duties include teaching courses, conducting research, and publishing academic work as well as contributing to community service, commonly known as tridharma in Bahasa Indonesia. Every academic staff member is expected to fulfil the tridharma annually. University workplaces do not differentiate between older and younger academics, and they provide the same services to all staff members . In Indonesia, the merit system for higher-education academic staff consists of five tiers. The first tier is junior lecturer, which is the entry-level for academic staff in higher education. The second and third tiers are lecturer and assistant professor, respectively. The fourth tier is associate professor, and the highest tier is full professor. Academic staff members must accumulate academic points to move up from one tier to the next. These points are earned through three primary functions: teaching, research, and community outreach. Academic staff members who are aged 60 and older have typically accrued significant experience and expertise through years of teaching, research, and community service at the university, making numerous contributions to the institution. Many of them hold the rank of associate professor or full professor due to their senior academic status, and they are generally highly regarded by both their colleagues and the university administration. --- Conceptual Framework Several academics have used various terms to describe social withdrawal among older people, though it is typically referred to as "social reductionism" . Sociologist Lars Tornstam introduced the concept of "social disengagement" as part of his theory of gerotranscendence, which involves a shift in perspective of older people on the emphasis and meaning of their social relationships. He suggests that this may lead to older people being more selective and less interested in certain social and personal relationships. Older people often experience social withdrawal and may have various types of it . The most common types are shyness, avoidance, and social isolation . Social isolation is typically defined as a lack of social contacts . Older people may experience social isolation for various reasons, such as deteriorating health, losing their spouses or partners, living alone, and having fewer confidantes . Other reasons are that cognitive and physical impairments may make people withdraw from social interactions . Moreover, older people tend to avoid using technology like the internet because of their cognitive and physical challenges, a behavior called "technology avoidance" . Internet technology can pose challenges for the current generation of older people, as noted by several scholars . There are three reasons why older people may disengage from online activities . First, older individuals may choose not to engage due to a perceived cost-benefit imbalance. Second, they may not feel the need to engage since it is not their responsibility. Finally, older individuals may be unable to engage due to a lack of technological proficiency, which can cause anxiety and a fear of making mistakes. Online technology may limit older people's participation in online questionnaire research . However, a different perspective has been proposed, claiming that online surveys may be more efficient for older people in a country where internet access is widespread . Furthermore, Kelfve and colleagues acknowledge that the online response rate for older respondents is lower and that a paper questionnaire should be provided as an option. Moreover, education appears to be a significant factor related to internet skills among older adults . In particular, older people with higher levels of education tend to have better internet skills than those with lower levels of education . --- Methods This paper reports on a study conducted at two prestigious public universities in West Java Province, Indonesia. This province has the highest population and the largest number of public universities in Indonesia, as well as a high percentage of older academic staff at its public universities . Furthermore, West Java Province is Indonesia's most populous province and shares a border with Jakarta Province, the country's capital. The public universities involved in the study are located in two different cities in West Java Province. This study was approved by the Human Research Ethics Committee of Universiti Sains Malaysia with the code number: USM/JEPeM/20050257. The ethics committee and the principal investigator agreed to keep the identities of all participants, institutions, and older people involved in the study anonymous. The data collected and used in this paper are presented as letters and numbers to protect the confidentiality of any person or institution. This research involved two public universities, referred to as University 1 and University 2. University 1 has 1,527 academic staff, of which 18.2 % are aged 60 and over. University 2 has a larger academic workforce , with 17.7 % of the staff aged 60 and older. The quantitative sample consisted of 277 older academic staff from University 1 and 309 from University 2, a total of 586 older academic staff. In this study, a sequential exploratory mixed-methods approach was employed, which involved both qualitative and quantitative methods. The first phase of data collection involved conducting semistructured interviews with top university administrators, including the rector, vice rectors, and directors at both universities. The qualitative findings from this phase were published in an international journal . The second phase was quantitative and used a questionnaire to collect data from older academics at both universities in the study. The questionnaire was distributed online to the participants, and an online pilot test was conducted before sending the actual questionnaire to respondents. The data collection for the quantitative part of this study took place during July and August 2021 in Indonesia, a period when the COVID-19 pandemic was at its worst. Consequently, all research activities that required physical presence in Indonesia and other data collection were conducted through online platforms such as Google Forms and WhatsApp applications. This study collected questionnaire data for nearly two months. In the first two weeks, liaison officers from the participating universities distributed the questionnaires to their colleagues via WhatsApp groups. However, this method did not reach many older academics, as there were fewer than 10 in the study sample. Therefore, the deadline for the questionnaire was extended by one week and a different distribution method was used. Due to the extremely low response rate of the first distribution, the liaison officers at Universities 1 and 2 were instructed to send out the questionnaire again but in a different way. According to the liaison officer from University 1, he re-sent the link to the questionnaire along with a cover letter to older academic staff members. The liaison officer from University 2 delivered the cover letter and questionnaire link to all deputy deans of resource affairs at the university, and urged them to disseminate it to all older academic employees. These methods increased the number of responses to about 30. The researchers also extended the deadline twice and contacted friends, colleagues, and acquaintances who had connections with University 1 and University 2. They helped to distribute the questionnaire or provided the contact details of potential participants. Through these efforts, the researchers recruited 41 participants for the study, which was a significant improvement from the initial response rate. --- Findings and Discussion This study has revealed two effects of social withdrawal among older academic staff. The first effect is their reluctance to participate in the research process. Out of the 586 older academics targeted in this study, only 6.99% or 41 respondents completed the research questionnaire, despite repeated attempts to encourage more participation. The respondents' academic levels were distributed as follows: full professors , associate professors , and assistant professors . Further details regarding the demographics of the respondents are presented in the table below. --- No. Selected One might assume that older academics' low rate of participation in the questionnaire was due to their difficulty or confusion with using technology; however, this assumption is not supported by the evidence from this study. The older academics who agreed to take part in the pilot study did not encounter any problems or challenges when they completed the online questionnaire. This is consistent with the findings of other studies indicating that older adults who have higher levels of education tend to demonstrate better internet skills compared to those who have lower levels of education . Thus, the older academics' low rate of participation in the questionnaire was unlikely to be caused by technological limitations, since most of them had high academic ranks of full professor or associate professor. This suggests that their low response to the survey was likely due to their avoidance of technology, as other scholars have observed , or disengagement from online activities because they did not have the motivation or feel the need to do so . This type of avoidance could be one form of social withdrawal . Moreover, it would be premature to infer that older academics' reluctance to participate in the questionnaire was attributable to either the complexity of the questions or an excessive number of questions. The evidence gathered from the pilot study, which also enlisted older academic members as participants, suggests that neither of these factors represented significant obstacles to completing the online questionnaire. The second effect of social withdrawal among older academic staff is the lack of policies for aging. Most of the older academics who participated in this study did not ask for any facilities or services from the university administration that could benefit them. Specifically, 65.9% of respondents reported never requesting specific facilities for older personnel, and 63.4% reported never asking for special services for individuals over 60. The study also found that older female academic staff were the least likely to request such services or facilities. The older academics who did not ask for any facilities or services for older people came from various schools, such as School of Language and Literacy, School of Education, Social and Humanities, School of Social Science, School of Science and Technology, and School of Medical Science. The older academics from the School of Science and Technology were the least likely to ask for facilities or services for older people. These findings highlight the importance of more research and policy development to support aging individuals in various academic settings. In general, universities may face serious consequences if they do not open a dialogue with older academics about their needs and issues related to aging. As some scholars have pointed out, decisionmakers may not be aware of the possible challenges that their older workforce is facing . This may lead to a lack of aging policies or inadequate services and facilities to support older staff. Moreover, older staff who are socially withdrawn or too shy to ask for support from university management may not get the fulfilment or support they need . Therefore, insufficient or nonexistent communication with older academics suggests that the university may not be ready to support its aging workforce, which can harm both the institution and its employees. Even though the older academics in our study did not ask for their needs to be met by the university administration, we found that they had their own strategy to cope with their problems; specifically, they sought help from younger staff . Furthermore, they explained that this situation was influenced by the local Indonesian culture of caring for and supporting each other. Other scholars have also argued that Indonesian people tend to choose informal ways of coping with their problems . --- Conclusion This research report has highlighted the significant impact that social withdrawal among older adults can have on data collection for research and policy formulation. The social withdrawal or social disengagement mentioned in the gerotranscendence theory alters the perspectives and interpretations of older people regarding social and personal relationships. As we found, older academics may be more selective and less interested in certain social and personal relationships. To ensure a comprehensive understanding of the needs and perspectives of older adults, survey research involving older adults should consider their social withdrawal characteristics. The findings of this study, particularly in the context of Indonesian public universities, suggest that older adults' social withdrawal may lead to a lower response rate, incomplete data collection, and a lack of formal and informal policies that support aging individuals. To address this issue, there is a need for more research involving older people from different socio-economic backgrounds and in other geographical contexts. However, based on this study, the universities that employ older people should start to recognize the need for an aging policy within the university institution that promotes inclusivity and accommodates the needs of all workers; this could have a significant impact on the prevention of social withdrawal, especially as employees get older.

Indonesia, the world's fourth-most populous country, sees a significant increase in its aging population each year. This demographic shift is reflected in the country's public higher-education sector, where the number of older academics has been growing substantially in recent years. However, older people's social participation is often limited due to certain forms of withdrawal, such as shyness, avoidance, and unsociability. This research report aims to explore the impact that these social-withdrawal characteristics among older people may have on data collection and policy-formulation processes in public universities in Indonesia. To gather data for this study, an online questionnaire was employed. The results of this study suggest that older people's social-withdrawal characteristics can have two effects. First, older individuals are often reluctant to participate in research, particularly as online questionnaire respondents, which can result in a lower response rate. Second, our study found that most older academic staff were unwilling to request or demand specific services or facilities from university administration, making decision-makers unaware of the needs of their older staff and aging issues in general. As a consequence, university administration may not consider instituting an aging policy at their institution, as they believe that older workers do not require special attention. This lack of awareness can have serious implications for the well-being of older academic staff and the overall effectiveness of university policies.

Introduction Sex between men remains the most frequent mode of HIV transmission in men in North America, Australia and western Europe [1]. Newly diagnosed HIV infections among men who have sex with men increased in Europe by 33% between 2004 and 2013 [2]. Similar trends have been observed in France, where MSM are increasingly predominant among newly diagnosed cases [3]. Incidence in MSM in France is 200 times higher than in the French heterosexual population [4]. Studies conducted since the epidemic began have shown how MSM have profoundly changed their sexual behaviours by implementing different strategies to manage the risk of HIV transmission. During the second half of the 1980s, MSM reduced their number of partners and began condom use on a widespread basis. During the 1990s, alternative strategies to systematic condom use emerged, such as negotiated safety with a steady partner [5]. Since 2000, condom use has fallen consistently regardless of partner type and HIV serostatus [5]. Simultaneously, alternative risk-reduction strategies have materialised under the umbrella term 'seroadaptation' [6,7]. These strategies include serosorting with partners of the same HIV status), seropositioning and selective avoidance of anal intercourse. In the meantime, the effectiveness of antiretroviral treatment has contributed to the medicalisation of prevention [8], although more evidence is needed on the efficacy of treatment as prevention among MSM [9]. More frequent testing among sexually active MSM [10] might shorten the delay between contamination and diagnosis [11], so that treatment could start as early as possible [9]. Furthermore, the availability of preexposure prophylaxis might reduce the risk of transmission in uninfected people [12]. In this context, preventive-behavioural and biomedical approaches need to complement each other [13]. In this article, we first describe the prevalence of sexual preventive behaviours by categorising the different risk-reduction practices according to respondents' HIV status. Second, we characterise the profiles of respondents with high-risk sexual practices to improve our understanding of the determinants of risk-taking. --- Methods The Presse Gays et Lesbiennes survey is one of the tools used for behavioural surveillance of HIV and other sexually transmitted infections among MSM in France [14]. The survey is anonymous, cross-sectional, self-administered and voluntary. The most recent survey questionnaire was inserted in paper format in a monthly gay magazine in June 2011 and posted on the Internet between May and July 2011, accessible through a study-specific website. Participants were recruited through more than 60 information and dating websites for MSM. Web banners, personalised messages and recommendations via Facebook were used to invite MSM Internet users to participate online. There were no inclusion criteria, but the voluntary nature of this study led to the exclusion of some respondents from the analysis. The exclusion rate was higher on the Internet than in the press . Of the 10,286 questionnaires completed by men from the Internet, 112 were excluded because respondents reported having had sex exclusively with women, three because respondents reported that they were younger than 14 years-old, and 779 because respondents reported they were not resident in France. Of the 1,110 questionnaires from the press, 54 from men not residing in France were excluded. The questions asked in the paper and Internet questionnaires were identical. Data were collected on sociodemographic characteristics, social behaviours, sexual and preventive practices. Specifically, respondents were asked to provide, separately for each steady or casual partner in the previous 12 months, information about oral sex, insertive and receptive anal intercourse, condom use, number of UAI episodes, and knowledge of partners' serostatus. Questions were also asked about HIV testing, both lifetime and during the previous 12 months, and selfreported HIV status at the time of the survey . The HIV status indicator is based on the lifetime HIV testing question and selfreported current HIV status. Excluded : no answer MSM: men who have sex with men. Seropositive MSM also answered questions about treatment , viral load, and CD4 count over the past 12 months. They were then classified into two categories -with controlled or uncontrolled infection. In accordance with the Swiss statement recommendations [15], control was defined in relation to both HIV infection and other STIs . Thus, regardless of whether they were on treatment, HIV-positive respondents who reported an undetectable viral load and a CD4 count greater than 500 cells/ µL in the previous 12 months and no other STI over the same period were considered to have controlled infection. All other HIV-positive respondents were classified with uncontrolled infection. Reported sexual prevention behaviours with casual partners in the previous 12 months were categorised into four mutually exclusive categories : no anal intercourse, consistent condom use, risk-reduction strategies, and no discernible prevention practice . These sexual prevention behaviour categories were applied to each serostatus: HIV-positive respondents with controlled infection, HIV-positive respondents with uncontrolled infection, HIV-negative respondents and untested respondents. --- Statistical analyses All statistical analyses were stratified on HIV status. Logistic regressions were performed to investigate bivariate associations between NDPP and sociodemographic and behavioural factors. All factors significantly associated in bivariate analyses with NDPP in at least one HIV status stratum were considered candidate variables for the multivariable analyses. Correlation and multicollinearity between these candidate variables were examined before entering them in multivariable logistic regression models. Interactions were also evaluated. The Hosmer-Lemeshow test was used to evaluate the goodness-of-fit of the final four multivariable models. Statistical analyses were performed with Stata software version 12.0. --- Results Overall, 10,448 men living in France responded to the survey, principally over the Internet . Our analysis was restricted to those who reported sexual intercourse with casual partners during the previous 12 months, self-reported their current HIV status and answered all the questions used in the multivariate analysis . Their median age was 37 years , 72% had a university degree and 32% lived in large urban areas . In the previous 12 months, 49% had had a steady male partner, and 23% had regularly frequented sex venues. The median number of sexual partners was 10 . Among all respondents, 14% reported at least one STI in the previous 12 months, and among HIV-positive respondents, 31% . --- Table 1 Definitions of four categories of sexual prevention behaviours, Presse Gays et Lesbiennes survey, France, 2011 --- Category of sexual prevention behaviour Definition No anal intercourse This category comprises respondents who did not report anal intercourse with casual partners in the previous 12 months but who may have had other types of sexual practices . --- Consistent condom use This category comprises respondents who had had anal intercourse with casual partners in the previous 12 months and had systematically used condoms both insertive and receptive intercourse. --- Risk-reduction practices --- Exclusive serosorting Respondents who reported they were HIV-positive or HIV-negative and had at least one episode of unprotected anal intercourse only with casual partners of the same serostatus as themselves in the previous 12 months, were classified in this category. --- Exclusive seropositioning This category comprises respondents who reported they were HIV-positive or HIV-negative and had at least one episode of UAI with casual partners of different or unknown serostatus from themselves in the previous 12 months, and had exclusively insertive anal intercourse for HIV-negative respondents and exclusively receptive anal intercourse for HIV-positive respondents. --- Serosorting and seropositioning Respondents who declared they were HIV-positive or HIV-negative and had at least one episode of UAI with casual partners in the previous 12 months, and who reported serosorting and seropositioning, were classified in this category. --- No discernible prevention practice Respondents who had had UAI with casual partners in the previous 12 months without implementing any of the risk reduction practices , regardless of their HIV serostatus, were classified in this category. --- Prevalence of sexual preventive behaviours with casual male partners The proportion of respondents practicing no anal intercourse with their casual partners in the previous 12 months was low: ranging from 2% among HIVpositive respondents with uncontrolled infection to 16% among untested respondents . Consistent condom use during anal intercourse was more frequent among HIV-negative respondents and untested than HIV-positive respondents . HIV-positive respondents with uncontrolled infection reported less consistent condom use than those with controlled infection vs 22% , p<0.001). Risk-reduction practices were reported more often by HIV-positive respondents , regardless of infection control status, than by HIV-negative respondents . Exclusive serosorting was practiced more than exclusive seropositioning, regardless of HIV status. No difference was found between HIV-positive respondents with controlled and uncontrolled infection for risk-reduction practices . NDPP was reported more frequently by HIV-positive respondents with uncontrolled and controlled infection , than by untested or HIV-negative respondents . --- Factors associated with no discernible prevention practice Univariate analysis showed associations between NDPP and a set of common variables, regardless of serostatus. These variables included age younger than 30 years, no university degree, and each of the following within the previous 12 months: regular frequentation of sex venues and dating websites, a high number of sexual partners, drug use, and exposure to sperm during oral sex. For HIV-positive respondents with controlled or uncontrolled infection, they also included HIV diagnosis after 2000. Multivariate analyses highlighted significant differences in the profiles of NDPP-classified respondents according to their serostatus. For HIV-positive respondents with controlled infection, NDPP was associated with age younger than 30 years = 2.9, : 1.1-8.0)), HIV diagnosis after 2000 ), and each of the following within the previous 12 months: regular frequentation sex venues ), more than 10 partners ), and exposure to sperm during oral sex ) . --- Table 4a No discernible prevention practice with casual partners of respondents who had a casual partner at least once in the previous 12 months, according to HIV serological status: bivariate and multivariate analysis, Presse Gays et Lesbiennes survey, France, 2011 --- Table 4b No discernible prevention practice with casual partners of respondents who had a casual partner at least once in the previous 12 months, according to HIV serological status: bivariate and multivariate analysis, Presse Gays et Lesbiennes survey, France, 2011 )), more than 10 partners ), exposure to sperm during oral sex ) and drug use ) . For untested respondents, NDPP was associated with all of the following activities in the previous 12 months: regular frequenting dating websites ), exposure to sperm during oral sex ) and drug use ) . --- Discussion --- Description of survey The Presses Gays et Lesbiennes survey is one of the very few surveys in France that describe the sexual behaviours of MSM in detail, based on a large sample of volunteers. Its use of the Internet as its principal mode of recruitment brought forth a wide variety of respondents, in terms of age, place of residence and sociodemographic profile. Because most respondents had had at least one casual partner in the previous 12 months, these data gave us a good understanding of prevention practices used by MSM in such relationships. --- Major results Because our categorisation of sexual prevention behaviours captures the diversity of preventive practices among MSM, we were able to obtain a detailed description of them. Thirty years after the HIV epidemic started, condom use during anal intercourse was not widespread, regardless of HIV status [1]. More detailed information about the determinants of consistent condom use would be interesting, but it seemed to us most useful to describe specific profiles of MSM engaged in high risk-taking in order to implement target prevention programs according to HIV status. Riskreduction strategies were used to a limited degree by HIV-positive respondents, with no difference according to disease control status, and to a lesser degree by their seronegative counterparts. Nevertheless, a large proportion of respondents had NDPP, a finding consistent with other European studies which used unprotected anal intercourse as the principal indicator of risk-taking [7,16,17]. The factors associated with this lack of protection reflect a number of common characteristics generally associated with risk-taking. These include frequenting Internet meeting sites, using drugs, and exposure to sperm during oral sex [17][18][19]. In particular, HIV-positive respondents with NDPP most often belonged to the post-AIDS generation and had an adventure-oriented sexuality [20]. HIV-negative respondents with NDPP were characterised by a low education level. --- Importance of HIV testing In this context, HIV testing and knowledge of status are major issues. More than one third of untested respondents and one in five of the HIV-negative respondents engaged in high-risk practices that put them and their sexual partners at risk for HIV infection and other STIs. MSM unaware of their status who engage in these behaviours contribute to driving the hidden epidemic, estimated in France to be more than 9,000 MSM [11]. A seroprevalence study in Paris showed that 20% of undiagnosed HIV-positive respondents reported that they either had never previously been tested or were HIV-negative, but had the same sexual risk behaviours as HIV-positive men aware of their status [17]. It is crucial that untested MSM be encouraged to go for HIV testing and receive counselling on risk-reduction strategies. Accordingly, structural and psychological barriers to testing must be reduced, especially denial about practicing at-risk behaviours and fear of positive HIV test results [21]. It is also essential for HIVnegative respondents to regularly update their HIV status. However, our results did not show any association between NDPP and testing within the previous 12 months. This suggests that these HIV-negative men had not actually recognised that they engaged in riskbehaviours and wrongly believed themselves to be HIV-negative. Encouraging MSM to test for HIV as frequently as possible to confirm their negative status is vital [21]. --- Risk-reduction practices and their limitations MSM have taken up serosorting or seropositioning as alternative risk-reduction practices to condom use [7]. Studies have previous associated these practices with positive HIV-status [22,23]. In our study, a substantial proportion of HIV-positive respondents used them, regardless of whether their infection was controlled or not. HIV-negative respondents also engaged in these practices, although at a rate lower than in other studies [22]. Nevertheless, the efficacy of both serosorting and seropositioning has been questioned. Their levels of scientific validation differ, and randomised trials have failed to demonstrate their efficacy. Some studies have shown they have a positive effect on the epidemic's dynamics [6], while others have not [24]. Unlike condom use, these practices do not protect against STIs and are only effective for HIV transmission if both partners have up-to-date knowledge of their serostatus [25]. Moreover, they must discuss the issue, something that cannot always be taken for granted, given the nature of meeting places and the problems of discrimination against seropositive MSM. --- Vulnerability of HIV-negative men who have sex with men HIV-negative respondents displaying NDPP appeared to be more socially vulnerable than other subgroups in our study. Although they were part of the gay community, they had profiles associated with high-risk sexual behaviours: young, with low education levels, and living in non-urban areas. The increase in newly diagnosed HIV cases among MSM under 30 years old in Europe [2,26], and in France more specifically [3], confirms our findings. Interventions targeting younger MSM are urgently needed to prevent a resurgence of the epidemic. Moreover, as in our study, a low educational level was found to be associated with risk-taking behaviours in the EMIS network [16] and with an increased risk of HIV seroconversion in European studies [26,27]. These findings must be integrated into prevention campaigns to tailor prevention messages as well as possible to ensure the widest possible participation by this specific population. --- Heterogeneity of practices among HIV-positive MSM Our findings underline the heterogeneity of preventive behaviours among HIV-positive MSM and the need to take this diversity into account to improve therapeutic care. In accordance with the Swiss statement's recommendations [15], in view of the different transmission issues, we categorised HIV-positive MSM according to whether their infection was controlled or uncontrolled and analysed them separately. Randomised trials have shown that treatment, by controlling viral load, reduces the risk of transmission in heterosexual couples [8] and in steady MSM couples [28]. No such result has been observed in MSM for casual relationships [9,29]. Interestingly, in our study, HIV-positive respondents with controlled infection were less likely to show NDPP than those whose infection was uncontrolled. This finding might be due in part to how we constructed the infection control status categories, by considering STI infections as well as viral load over the last 12 months. But this finding is also consistent with a seroprevalence study which showed that HIV-positive MSM in Paris with a low viral load reported a lower proportion of UAI episodes with casual partners of unknown or different HIV status than their counterparts with high viral loads [30]. The association of diagnosis after 2000 with NDPP, regardless of infection control status, demonstrates the generational impact and the effect of treatment on sexual behaviours [31]. A high proportion of the HIVpositive respondents in this study were diagnosed after 2000, at a time when barebacking was emerging and engendering fierce debates and long-term divisions between MSM in France [32]. Some of these men also started their sexual life after the arrival of antiretroviral treatment . Furthermore, the hypothesis of behavioural disinhibition linked to treatment seems be true for this sub-population [33]. These results highlight the urgent need to implement targeted information campaigns for HIV-positive MSM and thus to remind individuals and groups about the importance of treatment adherence, about STI care and about the place of condoms in sexual practices with casual partners. --- Study limitations Our study also has some limitations that must be considered in interpreting our results. First, the methodological limitations must be underlined. As is often the case for surveys related to MSM [14], our study is based on a non-random sample with participant self-selection through the Internet and gay press. Furthermore, the absence of both a sample frame and controls during the inclusion process means that our results cannot be extrapolated to the entire MSM population [1]. We did, however, use websites as varied as possible to invite MSM to participate. MSM recruited through the press have a more established sexual identity and sex life as well as higher educational and economic levels [34]. Those recruited through the Internet are younger and less urban [35]. Furthermore, the serological data based on self-reporting probably underestimated the real proportion of HIV-positive MSM as some respondents were probably unaware that they were HIVpositive. This point has previously been highlighted in studies on seroprevalence in MSM [17,36]. Second, the categorisation we used also has limitations. It was constructed retrospectively, based on the answers to questions about sexual behaviours and selfreported health status. It was not based on questions about a deliberate choice to use serosorting or seropositioning instead of condoms [37,38]. Nevertheless, a comparison of the risk-reduction practices and strategies matched the responses well: 90% of the respondents classified as engaging in serosorting declared they did so to avoid contamination by or transmission of HIV. Another limitation of the categorisation used is that making the risk-reduction categories mutually exclusive is simplistic and inaccurate. It does not take into account the protean reality of different sexual behaviours over time [37] and is the result of a theoretical compromise. --- Conclusions The study captured the diversity of preventive practices among MSM. Our findings highlight the ongoing nature of the normalisation of HIV in this post-AIDS era [39], when HIV has lost the central meaning it had in the lives of gay men in the 1980s and 1990s. Furthermore, the ever-decreasing use of condoms means that HIV testing and treatment are not sufficient to invert the epidemic's trend. Combination prevention is legitimate in the current context where HIV incidence remains very high worldwide. Accordingly, promoting condom use, encouraging regular HIV testing, offering treatment -be it post-exposure or pre-exposure -to HIV-negative MSM at high risk of exposure, prompt treatment of HIV-positive MSM and, finally, follow-up for STIs are all interventions that belong in prevention programmes for MSM within a global health approach. --- Funding The Presse Gays et Lesbiennes survey 2011 was funded by the French National Agency for Research on AIDS and Viral Hepatitis . --- Conflicts of interest None declared. ---

To better understand the diversity of practices and behaviours to prevent HIV with casual partners, data from a large convenience sample of men who have sex with men (MSM) in France were categorised into different prevention profiles: no anal intercourse, consistent condom use during anal intercourse, risk-reduction practices (serosorting, seropositioning) and no discernible prevention practice (NDPP). Categories were applied to HIV-positive respondents with controlled (CI; n=672) and uncontrolled infection (UI; n=596), HIV-negative (n=4,734) and untested respondents (n=663). Consistent condom use was reported by 22% (n=148) of HIV-positive-CI respondents, 13% (n=79) of HIV-positives UI, 55% (2,603) of HIV-negatives, and 50% (n=329) of untested (p<0.001). Corresponding figures for NDPP were 45% (n=304), 55% (n=327), 21% (n=984) and 34% (n=227) (p<0.001). Logistic regressions showed that, regardless of respondents' serostatus, NDPP was associated with regularly frequenting dating websites, drug use, exposure to sperm during oral sex, and with HIV diagnosis after 2000 for HIVpositive respondents (CI and UI), with age <30 years for HIV-positive-CI, and with low education for HIVnegatives. Risk-taking remains high, despite implementation of risk-reduction practices. A global health approach should be central to prevention programmes for MSM, to include target behavioural intervention, promotion of condom use, and encouragement of regular HIV testing and early initiation of ART.

Background In the face of the COVID-19 pandemic, governments have appealed to their populaces to engage in sustained behavior change en masse in an effort to reduce community infection rates. Effective and persuasive public health messaging has rarely been more critical, and will remain so until vaccines have been effectively distributed worldwide. A particular ongoing challenge has been persuading people to take precautions within their closest social networks. Indeed, evidence points to a disconnect between the contexts that people perceive to be high risk and those where the majority of transmission is actually happening. Several epidemiological studies have found that the vast majority of COVID-19 transmission occurs in homes [1], particularly at informal gatherings of family or friends [2]. Despite this, people are most concerned that they will become infected outside their homes, viewing strangers as the greatest threat, and public transport and crowds as the most dangerous environments [3]. These risk perceptions have real consequences for the precautions people take. For example, one large Australian study that was conducted at the height of the country's first COVID-19 wave in April 2020 found that while 84% of people were reducing their contact with strangers, only half were reducing contact in their workplace, and a mere 13% were reducing contact within their homes [4]. However, research to date has rarely distinguished between how people evaluate risk for different kinds of targets or in different contexts , instead focusing on global perceptions and protective behaviors [5,6]. To enhance the success of public health messaging, we urgently require a framework that can explain the nuanced patterns of COVID-19 risk taking. --- A social identity approach to risk Many of the behaviors recommended to reduce the spread of COVID-19 are fundamentally social behaviors . It follows then, that the science of social relationships is particularly relevant. One emergent social psychological framework that may help explain how people evaluate the risk of contagious disease is the social identity model of risk taking [7,8]. This model builds on the key principle of the social identity approach [9,10]: that our sense of self-definition is derived not only from our individual traits and qualities, but also from the groups we categorize ourselves as members of-our social identities. Crucially too, our social identities are not mechanistically determined by our "objective" group memberships, but rather, we subjectively and dynamically define ourselves in ways that are psychologically meaningful in a particular social context [11]. A person might be a resident of a neighborhood but feel no subjective affinity with it. Or, in contrast, a person might have a strong sense of identification with a neighborhood despite no longer residing there. When a person does define themselves in terms of a particular social identity, this has cognitive, emotional, and behavioral consequences. Indeed, our perception of the world is inextricably linked with how we define ourselves in relation to our own and other social groups [12,13]. Furthermore, when a particular social identity becomes salient to us, this affects how we perceive other peopleas fellow ingroup members, or as outgroup members. A large body of work has demonstrated that ingroup members are extended a variety of benefits, such as more positive interpersonal evaluations and greater trust, cooperation, and support [14][15][16][17]. This is particularly true for members of groups that are most important to us . Of these various benefits that tend to be extended to ingroup members over outgroup members, one of them greater trustmight have something of a dark side. Indeed, SIMORT argues that, because ingroup members are typically trusted to a greater degree than outgroup members, this has systematic effects on the degree to which we see ingroup members as a potential threat. Whether in the context of financial risk [18], corporate espionage, or most relevant for our purposes here, contagious disease, people tend to use shared group membership as a heuristic for 'safety' and are thus more likely to behave in ways that place their fate 'in the hands' of ingroup members. It follows from SIMORT, then, that social identity processes are central to an effective COVID-19 response because people systematically overestimate risks associated with interacting with outgroup members, while underestimating risks associated with interacting with ingroup members. Initial evidence for SIMORT comes from a variety of domains spanning large scale field studies at mass gatherings, longitudinal evaluations at festivals, through to controlled experimental laboratory studies. For example, American university students perceived drinking beer from cans emblazoned with their university logo to be less dangerous than from cans where such labelling was absent [19]. Along similar lines, in a sample of over 1300 young people at an Australian school leavers festival, researchers found that those who strongly identified with other festival attendees reported greater trust in fellow attendees and, in turn, rated as less risky behaviors such as sharing drinks, unprotected sex, or walking home alone while at the festival [7]. Another field study conducted at music festivals in the United Kingdom found that those who identified with fellow attendees reported reduced vulnerability to disease and a greater likelihood of engaging in health risk behaviors [20]. Finally, there is experimental evidence for SIMORT. One experimental study found that the need for personal space is attenuated when one shares a social identity with others, such that English university students in two lab experiments placed chairs closer together when their anticipated discussion partner was an ingroup member rather than an outgroup member [21]. Another experiment randomly assigned Australian university students to either a "green" or "red" group . Participants were asked to complete a Lego model that they were told had been commenced by a previous participant from the green group . The experiment also manipulated disease salience, with half of the participants encountering what appeared to be used tissues in the workspace, and the experimenter stating that the previous participant had a cold. After completing the Lego task, participants reported that they had taken a greater risk with their health in the disease salient conditions, but only when the previous participant was an outgroup member [7]. This suggests that in a context where the threat of contagious disease is salient, people are less sensitive to this risk when the source is an ingroup member. --- The current research Although this evidence is suggestive, the applicability of SIMORT to the COVID-19 pandemic is not yet clear. The context in which people evaluate the risk of social interaction has fundamentally changed, and pre-COVID research is unlikely to have fully captured the determinants of relatively novel health behaviors such as physical distancing. Therefore, the current program of research sought to urgently fill this gap and contribute to the COVID-19 response. The primary hypothesis, assessed across all three studies with Australian participants, was that shared group membership will increase trust in members of the ingroup, which, in turn, will reduce COVID-19 related risk perception and increase COVID-19 related risk taking. --- Study 1 Study 1 sought to examine this hypothesis in a community sample of people who expressed interest in getting involved in a social participation campaign in their local neighborhood. This two-wave survey was collected in collaboration with community not-for-profit organization Relationships Australia, with the original goal of providing an evaluation of Neighbour Daya grassroots community participation initiative to increase social participation and social cohesion. However, given that the baseline survey was distributed in the 2-4 weeks before the COVID-19 pandemic reached Australia, and Neighbor Day could not take place in its original form due to severe local restrictions, this project was redesigned prior to the Time 2 follow-up to enable the investigation of the present research question. --- Method Participants were 97 community members originally recruited prior to the pandemic via the Relationships Australia website and a mailing list of people who had expressed interest in the Neighbour Day campaign. Participants were aged 23 to 76 and were located in the seven different states and territories of Australia, with 79 different postcodes represented. Participants at Time 1 were entered into a prize draw to win one of two AUD$200 gift vouchers. At Time 2 , all participants received a AUD$30 gift voucher. T1 was completed in early March 2020 , prior to community spread of COVID-19 in Australia or the implementation of any local restrictions. T2 was collected from 6 to 30 April, during the most extreme national COVID-19 restrictions, including a stay-at-home order, forced closure of dine-in restaurants and cafes, and strict limits on household visits. However, daily exercise was permitted, including with people from other households if physical distancing was maintained. --- Measures Neighborhood social identification At T1, the four item social identification scale was included [22], with items such as "I see myself as a resident of this neighborhood" measured on a seven point scale from strongly disagree [1] to strongly agree [7], α = .84. Trust A one-item measure of ingroup trust adapted from prior research [23] was included: "People in this neighborhood can be trusted", which was rated on a seven-point scale from strongly disagree [1] to strongly agree [7]. Perceived risk of interaction with neighbors during lockdown A single item was adapted from previous risk research [7] to evaluate the perceived risk of interacting with neighbors during lockdown: "How safe or unsafe do you feel while interacting with people in your neighborhood?", which was measured on a seven-point scale from very unsafe [1] to very safe [7]. To aid interpretation, this item was reversed such that high scores represented a greater degree of perceived risk. --- Results To evaluate the hypothesis, a mediation model was specified in PROCESS [24] with 5000 bootstrapped samples in which the predictor variable was T1 neighborhood identification, the mediator was T2 neighborhood trust, and the dependent variable was T2 perceived risk of neighbor interaction. The key test of the hypothesis was a significant indirect effect, indicated by a 95% confidence interval that did not cross zero [24]. T1 neighborhood identification significantly and positively predicted T2 neighborhood trust, β = .49, p < .001. T2 neighborhood trust was, in turn, associated with lower T2 perceived risk of neighbor interaction, β = -.23, p = .045. Supporting the hypothesis, the indirect effect of neighborhood identification on perceived risk of neighbor interaction via trust was significant, β = -.11 . The model is summarized in Fig. 1. --- Discussion Study 1 found that people who identified more strongly as a member of their neighborhood prior to the COVID-19 pandemic were more likely to trust their neighbors during lockdown, and thus, perceived interacting with their neighbors during lockdown to be safer. A major strength of Study 1 was its pre-COVID baseline, which sets it apart from the majority of COVID-19 research and increases our confidence that our measure of neighborhood identification was 'uncontaminated' by the swift social and economic changes that occurred in response to the pandemic. However, limitations were its relatively small sample size and the fact that a baseline measure of risk was not available. Study 2 sought to address these limitations. --- Study 2 Study 2 was a multi-wave nationally representative survey of social psychological determinants of COVID-19 related behaviors. Study 2 sought to replicate Study 1 with several improvements including a large sample size, baseline measures of all variables, and a more behaviorally-oriented dependent variable. Furthermore, risk aversion toward other groups was also measured, to assess whether the effect of social identity processes on risk were specific to the ingroup. This is important because it is also possible that social identification is associated with generalized risk perception, whereas SIMORT proposes a specific effect on the risk arising from ingroup members. Study 2 occurred entirely during the period of COVID-19 restrictions, and so it was possible to analyze the data using a completely lagged design in which social identification with the neighborhood predicted change in trust and, indirectly, change in perceived COVID-19 risk. --- Method Participants were Australian residents stratified by age, sex, ancestry, and income. Recruitment was conducted using a Qualtrics panel, with participants paid the standard panel rate for their time. The sample was aged from 18 to 87 , and comprised 1071 women , 960 men , and 4 other . Due to the sampling strategy, the sample was diverse in geographic location , educational attainment, income, and ancestry. T1 was collected between 11 May and 27 May 2020, at a time when Australian governments were beginning to reduce some of the strict limitations that had been established throughout March . T2 was completed 2 weeks after restrictions were further eased to examine whether people maintained physical distancing when these behaviors were perhaps most importantas formal restrictions were reduced and the risk of community transmission was increasing. --- Measures Neighborhood social identification The single item social identification scale was used to measure neighborhood social identification, as follows: "I identify as a member of my neighborhood" on a sevenpoint scale from strongly disagree [1] to strongly agree [7]. This scale has been validated and widely used, with evidence suggesting it has comparable psychometric properties to longer social identification scales [22,25]. Trust A single item was used: "In general, I trust my neighbors" with response options from do not trust at all [1] to trust unconditionally [7]. This one-item trust measure was adapted from a validated single-item general trust scale, which has been widely used in population surveys [26]. --- Physical distancing from neighbors during lockdown Study 2 used a more behaviorally-oriented indicator of risk taking : the degree of actual physical distancing from neighbors that participants indicated that they engaged in. Participants were given the following background: "Social distance rules endorsed by the Australian government stipulate a distance of 1.5 meters between yourself and others. But really it is you that decides how much distance you keep from different people. Imagine walking down the street, how much distance do you think you would keep between yourself and the other persons listed below?" Different options were then presented including "a neighbor" , as well as "a person from another neighborhood", "a stranger" and "a close friend". Response options ranged from no distance [1] to more than 2.5 m [7]. Visual indicators of the distance between two people, modelled on local public health messaging, were included to aid interpretability. --- Results To evaluate the hypothesis, a mediation model was specified in PROCESS [24] with 5000 bootstrapped samples in which the predictor variable was T1 neighborhood identification, the mediator was T2 neighborhood trust, and the dependent variable was T2 physical distancing from neighbors. In addition, the covariates of T1 neighborhood trust and T1 physical distancing were also included, such that residuals in the mediator and dependent variable were the focus of the analysis. T1 neighborhood identification significantly and positively predicted T2 neighborhood trust, β = .18, p < .001, and T2 neighborhood trust was, in turn, significantly associated with reduced T2 physical distancing, β = -.11, p < .001. Supporting the hypothesis, the indirect effect of neighborhood identification on physical distancing via trust was significant, β = -.02 . The model is summarized in Fig. 2. --- Sensitivity analysis As an additional test of the model, we calculated the dependent variable as the difference between the degree of physical distancing from a person in one's own neighborhood and a person from another neighborhood. If significant, this analysis would suggest that the social identification is not related to a general tendency to physically distance from everyone , but rather its effects on risk are, as hypothesized, specific to the social group in question. This would strengthen our confidence that this is a social identity phenomenon. In this analysis, which in line with the primary model included T1 covariates, the effect of T1 neighborhood identification predicted T2 neighborhood trust , and trust predicted the difference between Fig. 2 Neighborhood identification indirectly predicts reduced physical distancing with neighbors during COVID-19 lockdown via trust. This model was adjusted for baseline covariates of T1 neighborhood trust and T1 physical distancing from neighbors. Therefore, this model illustrates that baseline neighborhood social identification predicts change in trust and physical distancing over time. Note. The curved line arrow in the figure represents the hypothesized indirect effect. The total effect of social identification on risk perception was β = .00, p = .757 distancing towards neighbors versus non-neighbors at T2 . The indirect effect was significant, β = -.01 . A final follow up analysis sought to evaluate whether the effects were specific to neighbors or generalizable to other groups by replacing the dependent variable and associated covariates with people from other neighborhoods, a stranger, and a close friend. In no case was there a significant indirect effect, or an effect of T2 neighborhood trust on physical distancing. --- Discussion Study 2 replicated the results of Study 1 and built on them in several ways. First, it was able to control for baseline levels of neighborhood trust and physical distancing, which increased our confidence in the direction of the hypothesized effects. Second, in Study 2 the measure of COVID-19 risk was based on self-reported behavior of a key COVID-19 preventative measure: degree of physical distancing. This increases our confidence that these psychological processes have public health implications. The hypothesized indirect effect and focal model pathways, although significant, were substantially smaller in Study 2 than in Study 1. This is likely due, at least in part, to the inclusion of covariates . However, another possibility is that the effects are more modest in size for risk taking compared to risk perception. A final strength of Study 2 was the inclusion of measures of physical distancing with non-focal groups, and we found that the effect of ingroup trust was specific to fellow ingroup members, and did not extend to other groups . --- Study 3 Study 3 sought to extend our analysis in two ways. First, it utilized an experimental design to provide the strongest test of the causal role of ingroup trust on COVID-19 risk. Second, it utilized validated multi-item measures of trust and risk behavior. Third, it included a control condition, with a view to investigating the inferences people make about trust and risk in the absence of explicit information about group membership. Fourth and finally, Study 3 aimed to provide an initial test of how the link between ingroup trust and COVID risk might be fruitfully used to inform the public health response. We reasoned that one of the greatest challenges of behavior change still ahead in combating the pandemic is persuading the global population to accept a COVID-19 vaccine. All vaccines have some risk associated with them, and these potential risks are often amplified and given undue emphasis by vaccine sceptics [27,28]. In line with our theoretical model, we reasoned that people will perceive a vaccine as less risky, and indicate a greater willingness to take the vaccine, if it has been developed and endorsed by ingroup members because of the greater trust we have for them. --- Method Participants were 216 Australian residents recruited for an online experiment via Prolific, an academic research web platform, between 13 and 17 August 2020when hundreds of vaccines were in development, but results of phase 3 trials were not yet available. Participants were 108 men and 104 women, with four people indicating that they were non-binary or choosing not to disclose their gender. Participants ranged in age from 18 to 72 and were diverse in terms of their educational attainment. Participants were paid the standard Prolific rate for their time . Study 3 was an experiment with three conditions: ingroup source, outgroup source, and control. Participants were asked to consider a hypothetical scenario in which a COVID-19 vaccine was announced in a press conference by Australia's medical officials. Participants first completed a social identification scale to make their social identity as an Australian salient. Participants were then asked to imagine that the following scenario in a speech attributed to Australia's chief medical officer. The control condition excluded the text in square brackets and did not attribute the vaccine or the risk evaluation to any particular group. "I am pleased to announce that a first vaccine for COVID-19 will, from tomorrow, be available to the Australian public. The vaccine was developed by [Australian/French] scientists and has passed the final stage of testing. It showed an 85% success rate in preventing the virus and carries only a 2% risk of serious side effects, which [our/France's] leading health experts consider an acceptable level of risk. Of course, this vaccine is being made available around the world, including in Australia. A website has just gone online where everyone can sign up to receive the vaccination, and indicate the doctor's surgery where they would like to receive it. This will be the first stage in rolling out the vaccine to all Australians." French people were selected as the outgroup for several reasons. We sought a real-world outgroup which was perceived by Australians to be of similar status and to be a nation about which Australians tend to have relatively neutral stereotypes . The design, measures, hypotheses and analyses were pre-registered . The pre-registration also included a power analysis, which indicated a recruitment target of 250 to achieve a minimum sample size of 207 for analyses. --- Measures Trust In Study 3, trust was measured using a comprehensive validated scale adapted from previous research [29]. As well as some items related to general trust, this measure included subscales relating to perceived integrity , benevolence and competence , each rated on a scale from disagree strongly [1] to agree strongly [5]. The underlined content was removed in the control condition. Two of the items from the original scale could not be readily adapted to the experimental context of Study 3, yielding a 19-item scale [7]. The scale has primarily been used as a single unitary indicator of trust in prior research [30] and the overall reliability suggested this was also appropriate here. Perceived COVID-19 vaccine risk Perceived risk of the proposed vaccine and willingness to take the vaccine was measured using four items adapted from prior research [7], each measured on a continuous sliding scale from not at all [0] to extremely [100]. The items were "How risky do you think receiving the vaccine is?", "How safe do you think having the vaccine is?", "How risky do you think not having the vaccine is?", and "How likely is it that you will sign up for the vaccine?". Three items were reversed such that higher scores represented a greater perceived risk of the hypothetical vaccine . In addition to the Cronbach's alpha, the unitary structure of these items was further supported by an exploratory factor analysis, which revealed only one factor with an eigenvalue > 1 that accounted for 70% the variance, with each item loading onto this factor at >.72. Manipulation check At the end of the study, participants were asked "In the scenario you were asked to imagine, which scientists had developed the vaccine?" with response options of "Australian", "French", "American", "I can't remember" and "It didn't say which scientists developed the vaccine". Participants in the ingroup and outgroup conditions were required to accurately identify the nationality of the scientists in their vignette to pass the manipulation check, while either of the final two options were acceptable to pass the manipulation check in the control condition. --- Results Initially, 250 people completed the study, however, in accordance with our pre-registered data management plan, 34 who failed the manipulation check were excluded. This left 216 participants in the final sample. The hypothesis was tested using PROCESS [24] with 5000 bootstrapped samples. Experimental condition was entered as the independent variable, trust in scientists was the mediator, and perceived vaccine risk was the dependent variable. All combinations of contrast coding were used in the mediation analysis such that comparisons were examined between each pair of conditions. Of these, only those comparing the ingroup source to the outgroup source were significant. This model is presented in Fig. 3. Participants in the ingroup condition expressed greater trust in the vaccine scientists, β = .53, p < .001. Trust in vaccine scientists, in turn, predicted a reduction in perceived risk and avoidance of the COVID-19 vaccine, β = -.23, p = .005. Supporting the hypothesis, the indirect effect was significant, β = -12. . Comparisons between the control condition and each of the group membership conditions revealed no significant effects except the effect of trust on risk, which was robust in all conditions. However, inspection of the estimated marginal means indicated that, rather than falling between the ingroup and outgroup conditions, the control condition most closely resembled the ingroup condition, albeit with a slightly wider variance that rendered its comparison with the outgroup condition nonsignificant. --- Discussion Study 3 provided several new insights. It replicated the previous studies in finding that ingroup trust is a key predictor of COVID-19 risk. However, Study 3 focused on a different domain of risk: perceived riskiness of and willingness to receive a COVID-19 vaccine. This is important because it suggests ways in which the general tendency towards ingroup trust might be utilized for effective public health messagingby emphasizing that vaccine development is an ingroup initiative being spearheaded by ingroup members. Of course, for many people around the world, the scientists developing COVID-19 vaccines will be outgroup members . However, shared identity can nevertheless be emphasized on dimensions other than nationality, potentially encompassing all of humanity [31,32]. Study 3 had several strengths over the prior studies, including its pre-registered experimental design and its use of more comprehensive validated measures of the constructs of interest. However, a limitation of Study 3 was that the findings may have been influenced by the specific ingroup and outgroup selected , and the real-world intergroup dynamics of these groups driven by normative content and status. The effects may have been quite different if, for example, a high status country had been selected as the outgroup. Findings should thus be generalized with caution, and with consideration of these dynamics. This limitation is best addressed in research by employing a minimal group paradigm, where the groups in question have no real-world "baggage" associated with them. Although this was not possible in the context of the present study, previous research has shown that the effects proposed in SIMORT also emerge in the context of such paradigms [7]. The comparison to the control condition provided some tentative evidence that in the absence of group membership information, participants may infer a shared group membershipat least in the context of a local vaccine roll-out or similar public health initiative. This is promising for intervention efforts, because it suggests that in countries where vaccine developers are an outgroup, de-emphasizing the nation of origin may reduce vaccine hesitancy. --- General discussion Across three studies, we have found evidence that COVID-19 risk and preventative behaviors are fundamentally structured by our group membershipsand most pertinently, by the greater trust that we afford fellow ingroup members. Study 1 demonstrated that people who strongly identified as a member of their neighborhood prior to the pandemic trusted their neighbors more during lockdown, and felt that interacting with them would be safer. Study 2 replicated this in a nationally representative sample of over 2000 people, finding that neighborhood social identification predicted positive change in neighborhood trust, which in turn predicted reduced physical distancing from neighbors. Study 2 also demonstrated that this phenomenon was sensitive to the specific group membership of the target group, with physical distancing from strangers, close friends, or people from other neighborhoods unaffected by neighborhood trust. Study 3 was a pre-registered experiment that sought to test whether it might be possible to harness these social identity processes in a positive way: to reduce perceived risk of a COVID-19 vaccine and increase willingness to receive it. Here, we found that participants who considered a vaccine developed by ingroup scientists were more likely to trust those scientists and, in turn, were less likely to perceive the vaccine as risky and were more willing to receive it. --- Theoretical implications The evidence presented here speaks to the nuanced understanding of group processes, and trust in particular, that is needed to accurately model health behavior. Of course, ingroup trust has many benefits, such as facilitating cooperation, helping, and, particularly relevant in this context, solidarity in the COVID-19 response [3]. However, ingroup trust also has some very concrete downsides, as demonstrated here. Similarly, there may well be situations in which the tendency to overestimate risk of outgroup members and underestimate risk of ingroup members is also beneficial. Indeed, this is a key argument of behavioral immune system researchers, who argue that people are largely accurate in their heuristic that outgroup members are a more likely source of disease [33,34]. Nevertheless, these studies illustrate that knowledge of group processes is crucial to the capacity of researchers, health professionals, and policymakers to accurately predictand effectively influence -COVID-19 related risk behaviors. The findings also speak to the utility of behavioral science, and social psychology in particular, to provide meaningful recommendations for tackling real-world problems. Indeed, as others have argued, this may be most especially true in times of crisis [35][36][37]. Although the COVID-19 pandemic precipitated an unprecedented investment in vaccine and treatment research , investment in behavioral science has been more muted. We argue this represents a lost opportunity at a time where behavioral science is proving crucial to effective decision making and communication [38]. --- Practical implications There are several implications of these findings for the practical management of the COVID-19 pandemic . First, they suggest that a particularly beneficial focus for public health messaging may be emphasizing the dangers posed by the people we are closest too . People require very little encouragement to avoid strangers and outgroup members. However, the perceived risk is lower in one's closest networks, and even if people are aware of these risks, they may be more likely to consider them worth taking. Therefore, investment is needed in messaging to provide people with guidance about how gatherings with loved ones can be made safer. Similarly, uptake of COVID-19 vaccination is likely to be greatest when promoted or developed by ingroup memberswho are perceived to be more trustworthy. "We are all in this together" has become a cliché in the COVID-19 pandemic, but it is a wise and effective government that is able to not only claim this axiom, but also embody it consistently in its public health messaging [39]. --- Limitations and future directions One notable feature of these studies is that they were all conducted in Australia, a country that has to date been relatively successful, globally speaking, in its COVID-19 response. COVID-19 risk in the community is therefore objectively lower than many countries, and risk perception may also be attenuated. However, it is worth noting that all three studies included participants based in Melbourne, which had recorded over 20,000 cases and 820 deaths at the time of writing and endured one of the longest and most restrictive lockdowns in the world. Therefore, it is not the case that Australia has been entirely spared by the pandemic. Future studies examining these effects might be particularly compelling if they were able to demonstrate that rates of COVID-19 transmission were affected by one's subjectively assessed group membership with, and trust in, the index case. Importantly, though, we would not expect overall differences in likelihood of transmission to differ between "low" and "high" identifiers with any particular social group. Rather, social identity can explain why certain people take risks with certain targetsand it is this more nuanced perspective on risk that warrants continued investigation in future research. --- Conclusions COVID-19 has become a pandemic when many other candidate viruses did not. This, we contend, is at least partly because it exploited fundamental features of human psychology: our strong desire for human contact, and our willingness to discount risk associated with our closest companions. In three studies, this paper found that our willingness to take risks associated with COVID-19 transmission is greater when the source of these risks is perceived to be a member of one's own valued social group. This tendency was fully mediated by our tendency to trust ingroup members, even in circumstances where this might be detrimental to our health. To tackle this and future pandemics more effectively, it is vital that public health messaging effectively communicates that transmission risk is often greatest with the people we care most about. --- --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: The social identity model of risk taking proposes that people take more risks with ingroup members because they trust them more. While this can be beneficial in some circumstances, in the context of the COVID-19 pandemic it has the potential to undermine an effective public health response if people underestimate the risk of contagion posed by ingroup members, or overestimate the risk of vaccines or treatments developed by outgroup members. Methods: Three studies (two prospective surveys, one experiment) with community-based adults tested the potential for the social identity model of risk taking to explain risk perception and risk taking in the context of COVID-19. Results: Study 1 was a two-wave study with a pre-COVID baseline, and found that people who identified more strongly as a member of their neighborhood pre-COVID tended to trust their neighbors more, and perceive interacting with them during COVID-19 lockdown to be less risky. Study 2 (N = 2033) replicated these findings in a two-wave nationally representative Australian sample. Study 3 (N = 216) was a pre-registered experiment which found that people indicated greater willingness to take a vaccine, and perceived it to be less risky, when it was developed by an ingroup compared to an outgroup source. We interpret this as evidence that the tendency to trust ingroup members more could be harnessed to enhance the COVID-19 response. Conclusions: Across all three studies, ingroup members were trusted more and were perceived to pose less health risk. These findings are discussed with a focus on how group processes can be more effectively incorporated into public health policy, both for the current pandemic and for future contagious disease threats.

INTRODUCTION Samarinda is the capital city of East Kalimantan Province, Indonesia. With the establishment of Ibu Kota Nusantara as the new capital city of Indonesia on August 26 2019 in Sepaku, a regency 70 Km away from Samarinda, Samarinda will become a destination for arrivals with various goals and interests. As a handicraft of an area, visitors generally need souvenirs as proof of having been to the area. One of them is traditional food of regional heritage . Gabin cake is a traditional food from Samarinda. The texture is like crackers or biscuit, but crumblier and more delicious. This is one of the factors that makes it an iconic dish. It's unclear where this iconic dish come from. However, in East Kalimantan, the people make it as food for typical souvenir of Samarinda . Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. --- 3 Based on the questionnaire of Samarinda popular traditional food, the results are shown in Figure 1. It can be seen that the top 3 traditional foods are amplang , nasi kuning and pisang gapit . It can be seen that gabin cakes are less popular than other traditional foods, it values 7.93%. The gabin cake industry is also not as many as other traditional food industries, only 2 business actors are officially recorded, namely the Ria and Lido industries. These industries have been established since 1969, and can be categorized as a cultural heritage because they have been more than 50 years. . From the literature study, there is also little discussion about the Samarinda gabin cake. There is also no manuscript discussing the design of gabin cake packaging, and no manuscript discussing Samarinda's gabin cake as the main topic. This is the reason for using gabin cake as a research object. From interviews with producers, gabin biscuits were originated from the story of ABK = anak buah kapal who once were often got seasick or nausea while sailing. At that time there was no hangover medicine or nausea reliever. Furthermore, the crew were given plain biscuits which turned out to be able to relieve nausea while sailing. These biscuits are easy to bite and odorless. Since then, these biscuits are popular with sailors, making them often called cabin biscuits. Gradually, the term cabin is often heard as gabin, so these biscuits are called gabin biscuits. This term is used by the industry to make the name of their product gabin biscuits, even though there are industries in other places that still use the name cabin biscuits . The characteristic of the people of Samarinda in eating this gabin by dipping it in hot tea. It is better to eat right after dipping it. Another way to enjoy it is by putting it on a plate, then douse it with warm tea, after it melts a little, it is spooned and eaten. If this gabin is eaten directly as other biscuits, it is tasteless and a bit hard. From the observations in the field, the packaging of gabin biscuits has not been developed since the first production. The identity of the region is not shown in the visual graphics. Consumers know this product comes from Samarinda from the industrial address written on the packaging. This case also occurs in other packaging of Samarinda's typical traditional heritage food. The Samarinda City Tourism Office categorizes regional identities as tourism enrichment for religious tourism, culinary tourism, nature tourism, maritime tourism, night tourism and shopping tourism . So, the local identity that will be explored in this study refers to this provision. Local snack packaging is a cultural expression that also emphasizes the identity of the community. This includes local cultural values . The iconic symbols typical of this region must be able to convey some elements that show the culture of the people, and can promote and inherit the culture. This traditional culture forms a valuable culture and unique style that offers a wide platform for designers to be applied in the packaging design, designers can create visual works with Samarinda's iconic features, while providing new meaning into packaging design . From this background, the problem that will be discussed in this research is what regional identity will appear in the packaging of traditional heritage foods. The result is a reference for the visual appearance in typical traditional foods packaging as souvenirs. So, by looking at the packaging, consumers will know where those products come from, and therefore they can become regional ambassador and regional promotion. Data from the analysis can be used to develop packaging designs, and can also be used by manufacturers and related agencies. --- THEORITICAL FRAMEWORK Traditional food is one of the products of local culture made by local people, using raw materials available in that place and processed in a unique way, with a typical taste of the local community . Traditional food arises from the needs of the people, and is produced from generation to generation . Local food is an inseparable part of an area. In its development, this typical food began to be developed by the community as souvenir, so that it could be categorized as an intangible cultural heritage item . Intangible Culture Heritage is an intangible cultural heritage referring to various manifestations of traditional culture that have been passed down from generation to generation. One of them is traditional food, which has meaning for descendants to study and research . Traditional food as cultural heritage can also be the main characteristic of the region's culture . With the emergence of advances in technology and science, traditional foods are getting rare due to the pressure of a competitive global market . According to Alver , tradition is important for many countries as a counter culture to dominant culture or globalization, because it gives new life to national identity, and to be expressed as national identity . As a souvenir, consumers need a container to carry it in the form of packaging. Packaging that shows regional characteristics and identity of origin with local geographic characteristics is more attractive to choose . Local food packaging as souvenirs is a cultural expression that also emphasizes the identity of the community. This includes local cultural values . Because souvenirs are memorabilia products as reminders or memories, the packaging must display visual characteristics of local culture as an effort to attract consumers . The problem with packaging traditional food as souvenirs is that it does not have maximum market appeal and local culture characteristic as visual appearance . Local Identity in Traditional food Packaging As Regional Identity. 6 2018). Packaging needs to be equipped with cultural elements from the region of origin to respect the cultural background of the region that will be conveyed in the packaging . From that case, many packages are presenting deep cultural elements, especially to respect the cultural background of what will be conveyed in the packaging . So the packaging can function as an ambassador, the ambassador representing the region of origin . Because one of the most important roles of packaging is to communicate to the user . Market are the meeting point for several products for customers, so packaging role is as a meeting point . Packaging is often be the first product attribute that consumers see, because packaging directly communicates with consumers and helps the customers to form their first impression to the product and decide will they buy it or not before experiencing the taste . The results of research conducted by POPAI , stated that 76% of purchases made by consumers were unplanned. Purchase decisions while in the store. Design, graphics, structure, product information and prices can cause impulsive buying. Manufacturers must be creative and attractive in displaying packaging, because packaging design encourages impulsive buying behavior . In packaging, visual displays are used to depict the symbolic relationship between culture and food. In popular food packaging, graphics define texture, organize, represent and influence the interaction of culture, food and media. Traditional food imagery is a medium for exploring and attracting consumers . Experts point out that visual elements such as images, colors, information, image density and packaging shape can trigger consumers' aesthetic perceptions and emotional responses, which in turn influence their purchasing intentions . Visual identity in packaging has an influence and social factors on consumer engagement and purchasing intentions when they see a product . It's not too difficult to design attractive packaging. However, the most important thing is to design unique packaging that presents the cultural connotations of the product as a form of innovation . Product innovation in packaging can include design developments that in turn lead to make changes in the function of product features . Local Identity in Traditional food Packaging As Regional Identity. Tai, Phuong, Hung, & Tung, 2023), among other things, the function of packaging as a container has developed into an identity function for the original region of the food. --- METHODOLOGY The method adopted in this study is the mix method. The first step is to spread the initial questionnaire to the respondents to explore the unique identity that they feel can represent Samarinda. The initial questionnaire received 35 respondents. The results of the initial questionnaire were discussed in the FGD and additional data obtained from 38 respondents, bringing all to 73 respondents. Data from respondents were discussed through FGDs with competent resource persons in their fields, they are historians, design experts and local tourism experts. The FGD was attended by participants from students, civil servants, traders and MSME entrepreneurs. The FGD result data is then qualitied using the NVivo application to illustrate the decision framework of the analysis result by coding the data according to a classification scheme that allows identification and indexing. The FGD obtained more specific data because it was processed according to criteria based on existing regulations, not from the number of questionnaire counts. While NVivo has great potential for sorting information, it does not replace researchers for data interpretation. Researchers need to read, synthesize, and draw conclusions from NVivo sorted data. The ability to sort and rearrange the result code data depends on to the the author's ability . --- RESULT AND DISCUSSION --- GABIN BISCUIT PACKAGING Gabin biscuits are packaged in transparent plastic containers in bulk capacity and in certain numbers. This clear visible packaging allows you to see the color of the food, the light coming through, as well as the appearance of the nomenclature and brand name . For bulk packaging, biscuits are wrapped in plastic, then tied with a rubber bracelet. Product information is in the form of printed paper inserted in the packaging, in the form of the company logo and the required information. For small packaging, biscuits are arranged in certain quantities and rows. The graphic display is as screen printed on the side of the packaging, but there is also printed paper inserted in the packaging. The regional identity or icon is not yet visible. Information on the origin of Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. --- 8 the product or identity of Samarinda is obtained from information in the form of text about the manufacturer and place of production. --- TOURISM TYPE GROUP The tourism office of Samarinda City in its roadmap classifies the types of tourism as shown in figure 5. Each of these tour groups has its own characteristics that distinguish it from other regions. The icon is then analyzed, which can be displayed in the packaging. Not all tourism categories can be displayed in the packaging, in this study icons were selected from religious, culinary, natural, bahari and shopping tourism. Because from the initial obtained data, the tourism category has several icons, it shlould be distinctive, has been legendary, and not owned by certain groups or regions. The icon is embodied in the form of shopping tourism icons, fauna icons, distinctive motifs, flora icons, taglines, religious tourism, marine icons, nature tourism, and infrastructure icons. --- SHOPPING TOUR ICON Shopping tourism icons are based on popular community shopping activities. In the form of sales locations, infrastructure, events or activities. The results of the analysis of popular traditional shopping icons in Samarinda are Citra Niaga , Pasar Pagi and Segiri Market . From those three shopping icons, the Citra Niaga icon was chosen, for it has the greatest value. Citra Niaga was inaugurated in 1987 as a shopping center for all business people, big and small. Traders with large capital occupy shop-houses, medium-sized sellers in kiosks, and street vendors in plots. A large tower was built near the main door in the form of a hornbill perched on a traditional roof. This icon is an inculturation of the local culture of Samarinda, from the Dayak and Kutai tribes. Located on the island of Kalimantan, many Samarinda business actors display regional motifs on their packaging. From observations in the field, the motifs used are generally Kalimantan traditional motifs, mostly motifs from the Dayak tribe. Dayak tribe inhabitants are scattered throughout the island of Kalimantan, so the people know that Dayak motif as characteristic of Kalimantan, but not specifically identify Samarinda. So, it is necessary to display typical Samarinda motifs, which are truly from Samarinda, which are distinct from motifs from other regions and can be applied in various media. For this unique motive, no data obtaining and analysis is carried out, but directly taking the motif which has become the official Samarinda motif which is strengthened by the legality of law. This motif is the Samarinda sarong woven motif. Sarong Samarinda or tajong Samarinda is a kind of traditional woven cloth from Samarinda, woven using a non-machine loom . The Samarinda sarong motif was established as the identity of Samarinda City starting in 2013 . Then it was inaugurated by the Minister of Education and Culture by designating the Sarong Weaving Samarinda cultural work as an object of Indonesian cultural heritage from East Kalimantan Province 2016 with registration number 2016000401 dated January 1 2016 . The motif used is the belang Hatta motif, box-shaped, with large and small varied sizes to form intersecting plots . This sarong motif is applied in various media as Samarinda's identity, so by looking at this motif, people will know where this motif came from. The motif is applied in buildings, interiors, gates, city symbols, uniforms, and various other applications. The silhouette of the Samarinda sarong is found on the official symbol of the Samarinda City Government. However, these results cannot be used as an option, because the black orchid has become the official mascot of the province of East Kalimantan . On the other hand, the specific flora of Samarinda has not been found, it is still as common as in other areas. So, there is no conclusion for the flora icon. Taglines are short sentences, easy to remember, provocative, usable to increase awareness. From people who don't know to know, and those who know to remember, because the tagline is mentioned or posted many times in every place. Taglines must have an identity, function like a logo but in text form. Tagline sentences can be in the form of common words, abbreviations, or local vocabulary. From the data collection, the popular tagline in Samarinda was obtained, shown in Figure 11. From the word cloud features, the most taglines used are tepian . Followed by etam , and magnificent . Tepian tagline, is an acronym for the words Teduh, Rapi, Aman dan Nyaman . This tagline is the official tagline for the city of Samarinda based on the Samarinda City Government Initiative Number 2 of 1998 dated January 21, 1998 Article 5 and has been approved by the Minister of Home Affairs in Decree Number: 001.234.4697 of 1998 . As a product that targets young consumers, several business actors use the current vocabulary tagline from the local language, including etam, peradaban, sanak, wadah. This tagline can be applied in packaging because it is popular, has regional characteristics and is less formal. On January 21, 2018, the city government launched the City of Samarinda Logo and Tagline, namely Magnificent Samarinda, as one of City Branding and a way to increase city promotion and marketing, both at national and international levels . However, this logo turned out to be polemic, because there are similarities or resemblances with other logos. The logo can be similar because the designer has the same inspiration for the object. To avoid problems that may come, such as plagiarism, the use of this logo for the packaging should be avoided. --- RELIGIOUS TOURISM ICON Samarinda as an old city is also famous for its religious nuances, so there are many religious tourist destinations with their own characteristics. The personification of religious tourism in this city is in the form of worship places, infrastructure, atmosphere of worship, history, and religious events/activities. Both icons also have unique characteristic when it is silhouetted. So that these two icons can be selected to be displayed in packaging as needed. Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. --- Figure 14. Islamic center Source: Prepared by Swiss Be Swiss-Belhotel Samarinda Figure 15. Shiratal Mustaqien Mosque Source: Prepared by redaksi 4.9 BAHARI ICON The definition of the word Bahari in Samarinda is a long time ago , 2023). Adapted from the Banjar language, South Kalimantan. Bahari means history, past, or things related to history. Bahari tourism here is related to historical tourism, civilization and development of Samarinda. The embodiment of Bahari tourism can be in the form of places, events, buildings, areas, regions or terms. From the word cloud feature, the bahari icons are kampung tenun , Pampang tourism village , Citra Niaga shopping center , ketupat village , tepian area . The icon of the kampung tenun in the form of building is embodied at the entrance of the village. The craft of this village is the Samarinda sarong, which has a distinctive motif. The typical motif of the sarong has become an iconic motif in the discussion in the previous sub-chapter. The commercial image icon can also represent shopping tourism as discussed in the previous sub-chapter. Pampang is a Dayak village, where the Dayak tribe is widespread in the Kalimantan region, so it is too general, because there are several tourist villages with this model in other areas, so it is not specific to address Samarinda. Kampung ketupat is a tourist village where the majority of the population produces ketupat . As a regional identity, this village has a distinctive icon in the form of a ketupat monument in the village which can show local identity. So, this icon can be considered to be used in packaging. Kampung ketupat is located on the banks of the Mahakam River, has a long history because it is an old village in Samarinda, so it is worth choosing. 4.10 NATURE TOURISM ICON Samarinda is blessed with natural diversity. This makes it attractive for natural tourism such as mountains/hills, forests, parks, rivers, waterfalls, lakes, and tourist villages or areas. Some of these natural attractions can become icons because of their uniqueness. From the data analysis, the displayed natural tourist destinations have values that are not much different. So, it requires a more in-depth discussion to determine it. The word cloud shows that the largest typical Samarinda natural tourism destination is the tepian area , Stelling hill , Berambai waterfall and Pampang tourist village . The tepian area includes along the Mahakam River and what is around it. This area has a long history following the history of the founding of Samarinda. The tepian area includes the Mahakam River, streams, infrastructure buildings, areas/villages. Some of the selected tourist icons in this manuscript are also in the coastal area, including Islamic centers, bridges, ketupat villages and Pesut fish. --- INFRASTRUCTURE ICON As the provincial capital and a buffer for the IKN, Samarinda carries out infrastructure development according to demands and needs in all fields. Some of these infrastructure buildings have distinctive architecture that can become regional icons. The infrastructure includes buildings, roads, bridges, airports, as well as regional planning. Some of the infrastructure icons that are discussed can be seen in figure 19. The summary of the tourism icons analysis can represent Samarinda to be applied to traditional heritage food packaging. It is shown in Figure 21. From the chart, several icons can represent several categories of tourism types. The combination of icons is used due to the limited surface area of the packaging. There is no analysis for the fauna and distinctive motif icons, because there have been official icons that have been protected by law. The flora icon can use typical icons that are common in Kalimantan, because it has become a public domain, so anyone can use it. Other icons can use the icon selected from the FGD results as a recommendation as needed. . Besides the local identity icons above, it is necessary to include some information on the packaging in accordance with the applicable laws in Indonesia. It should be conveyed because from the conditions in the field, there are still many business actors who do not understand this regulation, so they do not display it on the packaging. The ignorance is also due to the lack of outreach and guidance from related agencies. Some of these rules include: The 100% Cinta Indonesia logo launched in 2009 is a campaign to promote brands, goods and products of Indonesia, initiated by the Ministry of Trade of the Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. --- 20 Republic of Indonesia and the Ministry of Communication and Informatics of the Republic of Indonesia. The aims are to change the views of the Indonesian people who have so far considered that imported products have better quality than Indonesian products. The 100% Cinta Indonesia logo is free to be used on packaging by businesses because this logo is considered as a public domain. This is also one of the government's policies to support the resilience of MSMEs in the "Gerakan Bangga Buatan Indonesia " or BBI. The BBI policy is a government effort that combines society, the digital market and the government to support the use of domestic products produced by local MSMEs. Since the launch of the BBI policy on May 14 2020, business actors, the community, government and MSMEs have used the hashtag #proudofindonesia in their product content. This content is displayed on the product packaging . The attachment of the Wonderful Indonesia logo as a form of supporting tourism programs through creative industry products . This logo then has a derivative logo in each respective region, including in Samarinda as shown in Figure 23. This logo is displayed on the packaging as support for regional tourism. The information provided on the label must not mislead the consumer. On packaging labels, especially for food and beverages, at least the following should be stated : 1) Product name and trade name can also be included. Domestic products are written in Indonesian, and can be added in English. 2) List of ingredients used. 3) Net weight or net content. Solid foods are expressed in units of weight, while liquid foods are expressed in units of volume. 4) Name and address of the party producing or importing food into Indonesian territory. 5) Information about halal. 6) Expiration date, month and year. The shelf life of food products is usually written as: Best before date: the product is still in good condition and can still be consumed in a short period after the listed date has passed. Food products that have a shelf life of 3 months are written in date, month and year. The arranged regional identity icons then tested to analyze their application to the research object, in this study is Samarinda Gabin biscuit packaging. The results of the analysis are as the following description: From the preceding table it is known that the Gabin cake packaging which is used as the object of study visually has not been able to display Samarinda's identity through its distinctive icons. If a product is displayed in a window side by side with other packaging, consumers will not know where the product comes from and the products will be just as ordinary as the other products that are sold. Information regarding the origin identity of the product is written in the form of writing with no special graphic on the packaging. Consumers cannot know the origin of a product visually, they must first hold the product and read the information. This requires additional time and activity in the storefront. So, the packaging of the Samarinda Gabin cake needs to be developed from a visual standpoint. According to the industrial side, they don't develop the packaging because the packaging is already well known by consumers, so that when it is developed, the producers are afraid the consumers would not recognize it. From the statement of the relevant agencies, the city government, the packaging was not developed because it required a large amount of money to design it, which would add to the production costs of business actors. Then dialogue is needed between business actors and government agencies to solve the solution. Because this is related to business development and government programs to introduce their region through tourism programs. --- CONCLUSION Samarinda as the provincial capital is one of most visited area with various interests. While visiting, visitors are looking for something as a sign that they have visiting the place as souvenirs. Local foods are one of the souvenirs. One of them is Gabin cake. In bringing souvenirs, packaging is needed, where the local identity is displayed on the packaging, so that by looking at it, consumers will know where this product comes from. The packaging for this Gabin cake has not progressed, even if there are some changes, there has been little change. So, it needs to be reconstructed into modern packaging to make it more attractive without losing its original identity. One of them is by displaying the identity of the area. The selection of typical icons of the area through FGDs involving experts in their fields. The icons were chosen not from the large number of respondents' choices. The selected icon is checked against the existing regulations, cross-checked whether it has been used in other areas to avoid claims from other parties, because Some icons are sometimes similar to other regions. Some of these icons can represent several types of tourism. In its application, sometimes only a few icons will be used in the packaging due to the limited area of the packaging area. Advanced research can be developed by determining the standard attributes of traditional food packaging of Samarinda's heritage, so that a packaging design can be arranged and is ready for the production stage. --- JOURNAL OF LAW AND SUSTAINABLE DEVELOPMENT Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. DEVELOPMENT Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. DEVELOPMENT Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. DEVELOPMENT Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. DEVELOPMENT Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. DEVELOPMENT Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. Hidayanto, A., F., Hamat, B., Ariff, N., S., B., N., A. . Local Identity in Traditional food Packaging As Regional Identity. --- JOURNAL OF LAW AND SUSTAINABLE --- JOURNAL OF LAW AND SUSTAINABLE --- JOURNAL OF LAW AND SUSTAINABLE DEVELOPMENT --- JOURNAL OF LAW AND SUSTAINABLE --- JOURNAL OF LAW AND SUSTAINABLE --- JOURNAL OF LAW AND SUSTAINABLE DEVELOPMENT --- JOURNAL OF LAW AND SUSTAINABLE DEVELOPMENT --- JOURNAL OF LAW AND SUSTAINABLE DEVELOPMENT --- JOURNAL OF LAW AND SUSTAINABLE --- JOURNAL OF LAW AND SUSTAINABLE DEVELOPMENT

The main objective of this manuscript is to determine the typical icons of the city of Samarinda which will be applied in the visual appearance of traditional food packaging as souvenirs.The function of packaging has evolved along with packaging developments and technology. From its initial function as a container, one of its functions is to display the identity of the region where the product comes from through its visual appearance. Method: This research uses a mix method. Initial data was obtained from the questionnaire and then discussed through FGD involving experts in the fields of history, tourism and design. Next, it is processed with the NVivo application to illustrate the decision framework of the analysis results by coding the data according to a classification scheme that allows identification of regional icons that will be applied in packaging. Findings: Samarinda traditional icons which were obtained would be displayed on the packaging. They are the religious, culinary, bahari and shopping tourism groups, which are revealed in the form of shopping tourism icons, fauna, typical motifs, taglines, religious tourism, marine tourism, natural tourism and infrastructure. Research, Practical & Social implications: This paper will be useful for parties of similar interest, especially in the Samarinda area, who want to design souvenir packaging that displays regional identity in its visual appearance. Originality/value: Icons typical of Samarinda which can be displayed in souvenir packaging so that they can act as ambassadors for the region.

Introduction The Joint United Nations Programme on HIV/AIDS finally acknowledged in its 2010 report that the HIV incidence had declined by .25% between 2001 and 2009 in 22 sub-Saharan African countries [1]. The strongest evidence for the decline in Zambia is from the sentinel HIV surveillance of pregnant women, repeated population-based surveys in selected communities, and the 2001/2 and 2007 Zambia Demographic and Health Surveys [2,3,4]. National trend data on HIV prevalence among men are lacking. However, repeated population surveys in selected communities in Zambia showed that HIV trends among men were decreasing at almost the same rate as women [3]. These declines in HIV incidence have been mainly attributed to positive change in sexual behaviour [1,5,6]. The repeated population-based study in selected communities found parallel declines in HIV prevalence and number of sexual partners in the same sub-groups for both young men and women [5]. According to the UNAIDS 2010 report, young people accounted for 46% of all new infections in Zambia, with an estimated 120,000 young men and women currently being HIV positive [1,7]. After the 2001 United Nations General Assembly Special Session , Zambia renewed its interest in monitoring sexual risk behaviour indicators among young men and women [8]. To date, Zambia has reported twice to UNGASS on the progress made towards the targets set for HIV/AIDS in 2001 [8,9]. Seven indicators relating to HIV/ AIDS among young people have generally been monitored by UNAIDS, based on previous validation. These indicators include median age at sexual debut, premarital sex, condom use at last premarital sex, number of partners in the previous year, condom use at last higher risk sex, condom use at first sex, and age mixing in sexual relationships. Our study focused on only 3 of these factors, namely premarital sex, multiple partnerships and condom use at last premarital sex [10,11], since national data for these indicators were available for the period 2000-2009. In order to provide effective planning and delivery of HIV prevention programmes, understanding trends in risky sexual behaviour and what factors influence them, is important. Most previous studies on factors affecting sexual risk behaviours have been restricted to individual-level factors [5,12,13,14,15,16,17,18], but more recent evidence suggests that neighbourhood-level factors also play an independent and significant role in shaping behaviour [15,19,20,21,22,23,24]. Only a few studies have explored the effect of neighbourhood-level factors on HIV infection in Zambia [24,25,26,27]. One of these studies from Ndola [27], examined the effects of different measures of neighbourhood socio-economic status on HIV infection among young women in Zambia. Another study from Chelston and Kapiri Mposhi [26] examined the average neighbourhood educational attainment on HIV infection among young women. Both these studies found that neighbourhood characteristics were significantly associated with the risk of HIV infection. In this study, we used data from the 4 latest rounds of the Zambia Sexual Behaviour Surveys to examine trends in premarital sex, multiple partnerships and condom use at last premarital sex in different subgroups of young people. The effects of individual and neighbourhood-level factors on the 3 sexual risk behaviour indicators among young people were also assessed. --- Methods --- Settings Zambia is a landlocked country located in Southern Africa and has an estimated population of 13 million people [28], of which young people of ages 15 to 24 years make up 21.5% of the population. The HIV prevalence in Zambia is estimated to be 14.3% among adults 15-49 years of age [29], with the current prevalence among young men and women being 4.2 and 8.9%, respectively [1]. --- Data collection procedure The Sexual Behaviour Survey is a nationally representative population based cross-sectional survey that has been conducted in Zambia in 1998Zambia in , 2000Zambia in , 2003Zambia in , 2005Zambia in and 2009, and has collected data on HIV/AIDS/STIs knowledge, attitudes, sexual behaviour, and health-care seeking behaviours [30,31,32,33,34]. This data has been used to monitor national indicators proposed by international programmes, such as the Millennium Development Goals , UNAIDS, the President's Emergency Plan for AIDS Relief , UNICEF, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. However, the indicators monitored have been evolving with time and this has resulted in changes in the questions posed by the ZSBS. For example, the initial questionnaire used in the 1998 survey was based on the World Health Organisation / Global Programme on AIDS prevention indicators and the Family Health International general population surveillance questionnaire [30]. In 2000, an updated questionnaire was made with a new set of standards and indicators developed by an international consortium led by UNAIDS [31]. Over the years, adjustments have been made to the 2000 questionnaire to accommodate new indicators monitored by the international community. Although changes have been made to the questionnaires over the years, the core information on the indicators of interest for this study have remained the same [34]. But since the 1998 questionnaire lacked some of the standard questions included in the later surveys, it was excluded from the present analysis. Ethical approval for the ZSBS was granted by the University of Zambia Ethics Committee. All eligible participants were informed of the purpose of the survey, and both written and oral consent to participate in the survey was sought. Selected participants were given the option of accepting or declining the interview. For participants ,18 years, a parent or guardian was also asked for permission to interview them. This study was anonymous, and confidentiality was assured in all the 4-rounds of the surveys [30,31,32,33,34]. --- Sampling Procedure A 2-stage probability random sampling procedure was used in all 4-rounds of the ZSBS. The first stage of the sampling involved the selection of urban and rural clusters in every province of Zambia. These clusters, which we used as proxies for neighbourhoods, are census tracts or standard enumeration areas , with an average size of 130 households or 600 people [29]. In the 2000 survey, a total of 80 clusters were sampled from the sampling frame of 312 clusters of the 1996 Zambia Demographic and Health Survey . The number of clusters was increased to 100 in the 2003 survey, drawn from the 2000 Population and Housing Census as a sampling frame. The 2005 survey drew 105 clusters and the 2009 survey drew 100 clusters from the 2001/2 ZDHS sampling frame. In the period under review, a total of 385 clusters were selected in the 4 surveys and the distribution of these clusters between urban and rural areas was proportional to the national distribution of urban and rural residents [30,31,32,33,34]. The second stage of the sampling process involved the selection of households in the sampled clusters. About 16 households were sampled per urban cluster and 34 households were sampled per rural cluster. A higher number of households were sampled in rural clusters because rural households on average have fewer adult members. This resulted in a total number of sampled households to 1,851 in 2000, 2,497 in 2003, 2,465 in 2005, and 2,500 in 2009. All females aged 15-49 years and males aged 15-59 years in the selected households were eligible to participate in the survey. --- Variables Since the design of the ZSBS was not based on a theoretical model, the selection of variables to include in the analyses of this paper was based on an extensive review of published articles that have examined sexual behaviour [19,20,21,35,36,37,38]. The operational definitions and response categories of the selected variables for the analyses are presented in Table S1. Dependent variables. Three dependent variables considered for this study were: premarital sex, multiple partnership and condom use at last premarital sex. Premarital sex was defined as the number of young people who reported sexual intercourse in the last 12 months among all single young people [11]. This variable was derived from the question that asked if young people had ever had sex, but excluded all those who reported that they had sex for the first time when they were living with a partner and those who reported to be married, divorced or widowed. Young people who were not formally married were therefore excluded if they were living together with a partner, since a man and a woman living together for .3 months in Zambia are recognised as being married by customary laws, despite the absence of a marriage license. Multiple partnership was defined as the number of young people who had sex with more than one partner in the past 12 months among all sexually active young people, irrespective of whether these partners were concurrent or not [11]. Condom use at last premarital sex was defined as reporting use of condoms, and the denominator was young unmarried sexually active people, i.e. excluding those who were widowed or divorced [11]. Individual independent variables. The following independent individual variables were analyzed: sex, age, marital status, educational attainment, employment status, religion and urban/ rural residence . It is noteworthy that there was a change in the question concerning employment status between the 2003 and 2005 surveys. In the 2000 and 2003 surveys, the respondents were asked ''what kind of work they mainly did'' or ''their occupation''. Those who mentioned specific work or occupation were categorised as ''employed'', whereas students, family workers without pay, retirees, housewives and respondents who reported that they were not working were categorised as ''unemployed''. In the 2005 and 2009 surveys, respondents were asked whether they were employed or not, and those responding positively were categorised as ''employed'' and those not employed as ''unemployed''. Neighbourhood predictor variables. Variables describing characteristics of the neighbourhoods were created by aggregating individual responses within each cluster for all respondents aged 15-59 years [39]. Neighbourhood educational attainment was derived by aggregating individual-level years of school attendance. Neighbourhood labour force participation in 2000 and 2003 was based on the proportion of individuals who were categorised as employed on the question regarding their main kind of work done or their occupation, whereas in the 2005 and 2009 rounds, neighbourhood labour force participation was based on the proportion of individuals reporting that they were employed. As a proxy of social cohesion in the neighbourhood -an aspect of social capital, we created a variable that we called 'neighbourhood residential stability' by aggregating the number of years the participants had lived in the same neighbourhood. Neighbourhood comprehensive knowledge of HIV was based on the average number of correct responses made by respondents to the 5 questions presented in Table S1. --- Analyses All the analyses were restricted to young people . Descriptive statistics for the population distribution and variables are shown in Table S2, S3, S4 & S5. Trend analyses of the sexual risk behaviour indicators against the individual and neighbourhood characteristics, stratified by gender, were conducted using a Chi-square linear-by-linear trend test. In the trend analyses, the continuous neighbourhood variables were arbitrarily categorized into 3 levels: neighbourhoods with the lowest 40%, the middle 40% and the highest 20% [38]. Multilevel mixed effects logistic regression on the 3 sexual risk behaviour indicators were analysed using STATA 11.1 . All neighbourhood variables were analysed as continuous variables, but were standardised before running the multilevel analysis. The multilevel models tested included the following: These model tests were run for the 3 dependent variables using 2000 and 2009 data. Interaction tests were conducted for individual and neighbourhood variables, but none was found to be statistically significant. Other multilevel statistics estimated included the explained variance , the unexplained variance at the neighbourhood-level ) and loglikelihood tests. To estimate the explained variance of the models, we initially considered the formula suggested by Raudenbush and Bryk [40]. Using this formula, a negative explained variance was found after adding individual variables to the intercept-only model in 2000 for multiple partnerships and in 2009 for premarital sex. Raudenbush and Bryk's formula assumes that the sampling procedure used to obtain samples at all levels was simple random sampling, as such when the predictor variables are added to the models that had more group-level variance than the simple random sampling process produced, the apparent withingroup variance increased. This produced a negative estimate for the explained variance at the lower level [40]. To avert the negative explained variance problem, Hox [40] suggested a formula proposed by Snijders and Bosker [41] and it defined the explained variance in a multilevel logistics regression model as: R 2 ~s2 F s 2 F z t 2 0 z s 2 --- R Where: s 2 F is the explained part of the total variance, t 2 0 is the unexplained variance at the neighbourhood-level, and s 2 R is the unexplained variance at the individual-level . In the logistic distribution for the level-one residual, the variance is assumed to be a constant [41], which implies that the degree at which individuals belonging to the same neighbourhoods resemble each other. The intraclass correlation coefficient of a 2-level logistic intercept-only model with an intercept variance of t 2 0 is expressed as: r 1 ~t2 0 t 2 0 z p 2 3 The ICC at the neighbourhood-level is defined as the proportion of total variance between neighbourhoods [42], which is the same as the unexplained neighbourhood-level variance . The models were checked by goodness-of-fit test using the loglikelihood test. We also used the log-likelihood test to check whether adding covariates to the intercept-only model significantly improved the model fit. Associations with p,0.10 were taken as significant. --- Results --- Population sample and response rate In total 8,687 females and 7,803 males were interviewed between 2000 and 2009. The response rates were 88% in 2000, 87% in 2003, 88% in 2005, and 97% in 2009 among females, and 85% in 2000, 85% in 2003, 86% in 2005, and 88% in 2009 among males [30,31,32,33,34]. However, the focus of this study was young people aged 15-24 years, who totalled 6,500 participants in the years under review, i.e. --- Descriptive statistics In all the surveys, there were slightly more young women than young men who were interviewed. The majority had never married and lived in urban areas . The relative distribution of participants by gender, age, religion, urban/rural residence was relatively stable across the surveys. However, the proportion with secondary or higher education increased with time from 38 to 51%, as did the mean neighbourhood residential stability and comprehensive knowledge of HIV . The ''proportion employed'' in 2000 and 2003 was substantially higher than the ''proportion employed'' according to the definition applied in 2005 and 2009. Similarly, neighbourhood labour force participation estimates in 2000 and 2003 were much higher than the estimates in 2005 and 2009 . --- Premarital sex There was a 17% decrease in premarital sex among young women and men from 2000 to 2009 . The decline in premarital sex of young women was particularly marked among participants aged 15-19 years, those with low education, rural residents, and those residing in neighbourhoods with high educational attainment, low and medium residential stability and neighbourhoods with high comprehensive knowledge. However, an increasing trend in premarital sex was observed among young protestant Christian women. For young men, significant declines in premarital sex were seen irrespective of individual educational attainment or urbanrural residence and among those aged 15-19 years, protestant Christians, and those residing in neighbourhoods with medium educational attainment, low and medium residential stability, and low and medium comprehensive knowledge . In Table 2, the intercept-only model for 2000 shows that premarital sex varied across neighbourhoods with a neighbourhood difference of 5%, which was statistically significant at p ,0.05. The addition of individual-level variables in model-2 reduced the neighbourhood difference by ,40%, but only explained 27% of the variance of premarital sex. In model-3, the inclusion of neighbourhood variables in the intercept model reduced the difference between neighbourhoods to 2%, but these variables explained only 9% of the variance in premarital sex. The inclusion of both neighbourhood and individual-level variables in model-4 explained about 29% of the variance in premarital sex, while the difference between neighbourhoods was 2%, which was not statistically significant. The log-likelihood test showed that the addition of both individual and neighbourhood variables to the intercept-only model , significantly improved the fit. Model-4 also showed a number of statistically significant associations with background factors: older age, employment and being a protestant Christian were associated with higher odds of premarital sex, whereas residing in an urban area or neighbourhoods with high residential stability and high compre-hensive knowledge of HIV were associated with lower odds of premarital sex among young people . For 2009, the intercept-only model showed that premarital sex varied across neighbourhoods, with a neighbourhood difference of 11%, which was statistically significant at p ,0.05. Model-2 indicates that individual variables were much stronger predictors of premarital sex, such that their addition increased the unexplained neighbourhood-level variance from a proportion of 0.40 to 0.78. The inclusion of these variables explained 33% of the variance in premarital sex. Model-3, with neighbourhood-level variables, had a very low neighbourhood variance of premarital sex among the neighbourhoods. In contrast, model-4, which included both neighbourhood and individual-level variables, explained ,34% of the variance in premarital sex, but the difference between neighbourhoods remained at 11%. The loglikelihood test revealed that despite these results, the inclusion of both individual and neighbourhood variables significantly improved the fit. Model-4 also showed that 2 individual-level variables were significantly associated with higher odds of premarital sex among young people. Urban residence and residing in a neighbourhood with high labour force participation and high comprehensive knowledge of HIV gave significantly lower odds of reporting premarital sex . --- Multiple sexual partners There was no clear overall trend in multiple partnerships among young women between 2000 and 2009. However, a statistically significant decrease of ,45% was generally observed among young men, and almost all subgroups showed statistically significant declining trends. The only subgroup of men where a decline could not be seen was among those living in neighbourhoods with high comprehensive knowledge of HIV, but the change was not statistically significant . The intercept-only model in 2000 showed that multiple partnerships varied across neighbourhoods with a neighbourhood difference of 14%. The addition of individual variables in model-2 reduced the neighbourhood difference in multiple partnerships to 10%, whereas these variables explained ,29% of the variance in multiple partnerships. Model-3 showed that the inclusion of neighbourhood variables explained ,2% of the variance in multiple partnerships. The addition of both individual and neighbourhood variables in model-4 explained ,29% of the variance in multiple partnerships, while the difference between neighbourhoods was reduced to 9%. Model-4 showed that the inclusion of both individual and neighbourhood variables significantly improved the fit. Being female was the covariate significantly associated with lower odds of multiple partnerships in model-4. However, having secondary/higher educational attainment and being in employment were significantly associated with higher odds of multiple partnerships among young people . For 2009, the intercept-only model showed an extremely low variation in multiple partnerships across neighbourhoods. Model-4, however, showed that being females and residing in neighbourhoods with high comprehensive knowledge gave lower odds of having multiple partners . --- Condom use at last premarital sex Condom use at last premarital sex generally remained stable among men between 2000 and 2009, whereas it decreased nonsignificantly among women. Significant falling trends occurred among women in neighbourhoods with medium residential stability and low comprehensive knowledge of HIV . Model-1 for 2000 showed that condom use varied across neighbourhoods, with a neighbourhood difference of 18%. The addition of individual variables explained ,10% of the variance in condom use among young people. The difference across neighbourhoods was reduced to 9%. Model-3, with neighbourhood variables only, explained 15% of the variance and the difference across neighbourhoods was reduced to 5%. Model-4 explained ,18% of the variance, whereas the difference across neighbourhoods was reduced to 3%. The background variables that were significantly associated with lower odds of condom use in model-4 were being a protestant Christian and residing in neighbourhoods with lower labour force participation. Young people residing in neighbourhoods with high educational attainment had higher odds of condom use . The intercept-only model in 2009 showed that condom use varied across neighbourhoods, with a neighbourhood difference of 12%. The inclusion of individual variables in model-2 and neighbourhood variables in model-3 reduced the differences across neighbourhoods to 2 and 3%, respectively. However, individual variables explained ,7% of the variance in condom use, while neighbourhood variables explained ,6% of the variance. The addition of both individual and neighbourhood variables in model-4 reduced the difference between neighbourhoods to an extremely low level. Young people residing in neighbourhoods with high residential stability and high comprehensive knowledge of HIV had higher odds of condom use . --- Discussion Sexual behaviour surveys based on the nationally representative samples of young adults in Zambia showed a decline in premarital sex for both females and males between 2000 and 2009. A substantially downward trend of multiple partnerships occurred among young men, whereas the proportion with multiple partnerships among young women during this period was relatively low and stable. However, condom use at last premarital sex remained relatively stable among males over the years, but decreased among females. These findings have also been reported in the 2009 Zambia Sexual Behaviour Survey report [34]. In this study, we have also shown that the decline in trends also occurred in most sub-groups of young people for premarital sex and multiple partnerships . Multilevel analysis further showed that both individual and neighbourhood variables influenced young people's sexual risk behaviour in both 2000 and 2009. --- Trends in sexual risk behaviours It is clear from our findings that the downward trends of premarital sex provide a good indication that young people are postponing their sexual debut in Zambia. The decline does not seem to be due to an increased rate of early marriage, since the proportion of young people who had never been married decreased. Combined with decreasing trends of multiple partnerships among young men, this suggests positive sexual behaviour changes among young people in Zambia. The behavioural changes could have contributed to the decline in HIV incidence in Zambia since 2001. It is possible that the decline in premarital sex and multiple partnerships is a sign that HIV prevention campaigns promoting abstinence and faithfulness to one partner could have had an impact. It is also likely however that young people's personal experience of the effects of the HIV epidemic have led to these behavioural changes [43]. One of the targets set in the millennium development goal-6 was to increase condom use during high-risk sex among young people to . 90% by 2015 [44]. Despite extensive condom promotion in Zambia, condom use at high risk sex is currently estimated to be 40% [34]. In fact, condom use at last premarital sex has remained consistently low since 2000. The evidence indicates that there are many social barriers to condom use, for example, the influence of the church. In a study analysing data from the 2003 Zambia Sexual Behaviour Survey found that more than two-thirds of the participants believed that condoms promoted promiscuity [25]. Other factors affecting condom use include lack of money to buy condoms, the infrequent supply of condoms, long distance to outlets, stigma, lack of knowledge and gender inequality [25,45,46]. --- Associations between predictors and sexual risk behaviours Findings from the multilevel analyses offer insights into possible neighbourhood contextual effects on premarital sex, multiple partnerships and condom use among young people in Zambia. We have shown that the addition of individual factors to the interceptonly model substantially reduced, or in some cases increased, the difference between neighbourhoods. Increase in the total unexplained neighbourhood variance of premarital sex and multiple partnerships compared to the intercept-only model's variance when the individual-level factors were added to the models may be explained by the fact that the formula used assumes simple random sampling, so when grouped data are entered into the model, the lower level variance tends to increase [40]. However, several individual factors were associated with increased risk of premarital sex and multiple partnerships. In contrast, the condom use indicator had very few statistically significant associations with the individual factors; the probable reason could be that the small sample size within the clusters might have reduced the power to detect significant associations with the outcome factors. This study also found that urban residence was significantly associated with lower likelihood of premarital sex and a higher likelihood of condom use in both 2000 and 2009, suggesting reduction in sexual risk behaviour among young urban males and females. These findings support the observation that HIV prevention efforts have been more intensive in urban settings. An example of this can be drawn from the condom distribution campaigns in Zambia, where an estimated 14 million condoms were distributed in 2008, with the majority of the distribution outlets being located in urban settings [8]. Furthermore, due to the high prevalence of HIV in urban areas, urban residents are more likely to have greater personal experience of HIV/AIDS and may perceive themselves at higher risk of infection and thus be more motivated to avoid risk taking. To check for independent neighbourhood effects, we entered neighbourhood factors into the intercept-only models. This resulted in a substantial decline in the unexplained variance of premarital sex and condom use at last premarital sex at the neighbourhood-level. This suggests that neighbourhood variables have a considerable influence on the sexual risk behaviour indicators. To assess the neighbourhoodlevel variance explained by these variables, we initially considered the formula suggested by Raudenbush and Bryk [42]. We could explain 62% of the variance of young people's premarital sex in 2000, and 72 and 75% of the variance of young people's condom use in 2000 and 2009, respectively, which were high proportions. For this particular formula, the explained intercept variance is based on a comparison of the intercept-only model and the model without random slopes, and thus has the two weaknesses pointed out by Hox [42]. First, it is possible to arrive at the conclusion that specific factors contribute negatively to explained variance, and second in random slope models the estimated variances depend on the scale of the explanatory factors [42]. Conversely, using the formula suggested by Snijders and Bosker [41], their explained variance is a proportion of the total variance, because first level variables in principle, can explain all variation, including that at the second level [42]. This formula removes the spurious increase in variance when variables are added to the intercept-only model, thus avoiding the negatively explained variance. Neighbourhood residential stability was a statistically significant predictor of both premarital sex and condom use . We argue that this predictor can be used as a proxy for social capital [38], since the longer people stay in the same neighbourhood, the more they are likely to interact with each other, build trust and develop a strong community solidarity [47]. This social cohesion has an impact on young people's sexual risk behaviour [48,49]. Our study supports this, since we found that, per unit of increase in the variance of average length of residence in the neighbourhoods, the odds of premarital sex decreased and that of condom use increased among young people. High neighbourhood residential stability is likely to increase social control over young people's behaviour, thus limiting their perceived opportunities to engage in premarital sex [38]. Other studies have found that young people in communities with a high social capital have a higher tendency to delay their sex debut and use protection during sexual intercourse [49]. Another striking neighbourhood predictor of lower risk of premarital sex and multiple partnerships, and higher condom use in our study, is comprehensive knowledge of HIV. The 2007 Zambia Demographic and Health Survey indicated that .90% of Zambia's population were aware of HIV, but only 37% of young men and 34% of women had comprehensive knowledge of HIV transmission [29]. This is way below the 95% target set in the 2001 UNGASS Declaration [1]. Although knowledge alone is not enough to change behaviour [50], these findings support earlier evidence that an increase of comprehensive knowledge of HIV reduces the risk of new infections, especially among young people [1,51]. Neighbourhood educational attainment may be viewed as a proxy for neighbourhood socio-economic position. High neighbourhood socio-economic position has been found to reduce the risk of premarital sex [21]. In contrast, another study found that women in communities with a higher proportion of educated community members had significantly greater odds of engaging in premarital sex than those with lower proportions of educated people [38]. Our study however found that neighbourhood educational attainment was only significantly associated with condom use in 2000. At the individual level, young educated people tended to have higher odds of engaging in premarital sex and having multiple partners. This may reflect that young people with high education may feel more liberated from social norms that restrict premarital sex than their less educated peers, possibly because they are absent from home attending school. However, these findings are surprising considering that a number of studies in Zambia have shown a clearer decrease in sexual risk behaviour [5] and HIV prevalence among educated young people than the less educated since the late 1990s [2,3,5]. The different aspects of average neighbourhood employment, for example labour force participation, the prevalence of full time employment, and employment opportunities, have been used as proxies of the ability of adults to supervise young people's behaviour [20].This is because neighbourhoods with high employment rates usually comprise people who are highly educated, and they are often characterised by family stability, high levels of parental authority and control, availability of parental time and supervision, and increased communication between the young people and their parents [52]. We found that neighbourhood labour force participation was associated with more premarital sex and less condom use in 2000, but neighbourhood labour force participation was associated with less premarital sex in 2009. The findings may reflect that the questions regarding employment status in the early and later surveys measured different aspects of employment, which may have caused the differences seen between the early and later surveys in the regression analyses rather than this being a major change in the association between sexual behaviour and employment status. To measure the mediating effects of individual and neighbourhood factors, they were entered into the same model. For example, the full multivariate model for premarital sex in 2000 showed that neighbourhood labour force participation became statistically insignificance. It is possible that neighbourhood labour force participation was a confounder in model-3 and that the important association was between the individual-level employment status and premarital sex. Furthermore, neighbourhood comprehensive knowledge in 2000 lost its statistical significance in the full multivariate models for multiple partnerships, which might have been a result of partial confounding of the effect of rural-urban residence variable. Urban-rural residence seemed to be a confounder in relation to condom use at last premarital sex in 2000, since the significant association seen in model-2 disappeared when adjusted for neighbourhood educational attainment and neighbourhood labour force participation. In contrast, after the urban-rural residence variable was added to the full multivariate models in 2009, neighbourhood comprehensive knowledge became a significant predictor of multiple partnerships, neighbourhood residential stability became significantly associated with condom use at last premarital sex, and neighbourhood labour force participation became a significant predictor of premarital sex. In these cases urban/rural residence seems to have functioned as a negative confounder that distorted the true association toward the null. --- Limitations of the study The results of this study should be considered with some caution. For instance, it was based on self-reported sexual behaviour data, i.e. subject to bias. Some studies have found considerable errors in self-reporting of sexual activity, for example, males over-reporting and females under-reporting their sexual activities [53,54,55]. This may also have been the case in our data since men reported on average many more partners than young women. Young men are subtly expected in most cultures to display high heterosexual activity, whereas young women are expected to be chaste [15,56]. Therefore, the difference between the reports of men and women may be due to men overstating their reported number of sexual partners [57]. Furthermore, it is possible that using face-to-face interviews to gather this type of information may have contributed to reporting errors as people might not reveal all their sex life details to a stranger. If the magnitude of the bias has changed over time, this would have affected our trend estimates. The cross-sectional nature of the data limits our ability to draw causal inferences about the associations we have found. Moreover, the use of repeated cross-sectional studies conducted in different clusters, with different households, to estimate trends would affect estimates if there had been a major population shift over the years being analysed. However, such major shifts do not seem to have occurred. The number of neighbourhood and individual-level variables used in this study was restricted by the changes in the questionnaires over the years. Large proportions of the total variance of the three indicators were not explained by the individual or the neighbourhood factors, and the explanation for this could be that we did not include all the important factors. We have only assessed trends in 3 sexual behaviour indicators, and there may be other important aspects of changes in sexual behaviour among young people that might have been missed [10,11]. The small sample size, especially for the analysis of multiple partnerships and condom use, might have resulted in low power to detect differences at both individual and neighbourhood levels. --- Study Implications To be useful to policy makers in Zambia, future neighbourhood research on the effect of neighbourhood on sexual risk behaviour should not only be focused on whether neighbourhood factors influence sexual behaviour but begin to tackle critical questions of how these factors affect sexual risk behaviour. Furthermore, there is need for these future studies to be based on theory at design stage, for example, the Social Capital theory or the Ecological model of human development, so that the relationships found can be properly explained. --- Conclusion This study showed that premarital sex and multiple partnerships have been decreasing over the years but condom use has remained almost stable since 2000. In addition, the present study showed that both individual and neighbourhood contextual factors played a considerable role in influencing the sexual risk behaviours of young people. --- Supporting Information ---

Objective: This study examined trends in premarital sex, multiple partnership and condom use among young people (15-24 years) in Zambia from 2000 to 2009, and assessed the effects of individual and neighbourhood variables on these sexual behaviour indicators in 2000 and 2009.

Introduction Well-being is an elusive construct, which defies easy and unambiguous definition. Understanding the nature and structure of well-being has been one of the challenging tasks in social science research and philosophy. At the philosophical level, there are several rival theories which make competing claims about what well-being consists in [1]. In empirical research too, a number of operationalizations, conceptualizations, and definitions of the well-being --- Measurement of societal well-being Gaining insight into the nature of societal well-being has been inextricably linked with the question of how to measure this construct. The construct has traditionally been measured using economic indicators such as national income per capita and gross domestic product per capita [6]. However, in recent years the inadequacy of economic indicators as proxies of well-being has been widely recognized and discussed . A number of non-economic dimensions of well-being had been systematically proposed, initially within the social indicators movement in the late 1960s and 1970s, to supplement economic measures as indicators of a country's prosperity and progress [8]. Beyond the academic sphere, governments and international organizations too have increasingly recognized the need to go beyond economic measures. The UK, for example, instituted a programme entitled Measuring National Well-being, using a wide range of wellbeing measures, following the then Prime Minister, David Cameron's 2010 declaration of intent to measure national progress 'not merely by standard of living, but by quality of life'. Similarly, France has introduced quality of life measures in response to the findings of a Commission on the Measurement of Economic Performance and Social Progress [9]. Other developed countries, and international bodies such as the European Union and the OECD have introduced similar initiatives [10]. The predominant view in modern well-being research is that societal well-being is essentially a complex, multidimensional construct, including both objective and subjective indicators, and accordingly a comprehensive assessment of well-being must also capture both these aspects [11,12]. The objective approach, originating in economics, focuses on material resources and objective indicators as proxies for well-being, whereas the subjective approach, originating from social survey research and psychology, concerns how individuals experience their lives and focuses on subjective evaluations of life and individuals' inner feelings [13,14]. The multidimensional approach to human well-being still needs to answer the question of which dimensions should be included in the conceptualization of well-being. This problem is especially evident regarding subjective indicators, due to a variety of well-being models developed in psychology over the past few decades. In general, well-being models in psychology take one of two relatively distinct, yet overlapping approaches to human wellbeing: the hedonic perspective and the eudaimonic perspective [15][16][17], which are discussed below. --- Hedonic/Subjective well-being The hedonic perspective on well-being emphasizes the cognitive and affective evaluations of one's life, and is usually operationalized as subjective well-being , which includes positive affect, negative affect, and overall life satisfaction [18]. Probably the most widely used and reported SWB indicator has been life satisfaction, which is increasingly being promoted as an alternative measure of well-being to inform public policy [19]. Consequently, most large-scale surveys of quality of life include a single-item scale of life satisfaction as a key measure of well-being. Outside the realm of empirical social science, some philosophical theories define well-being in terms of life satisfaction [20]. Life satisfaction's attractiveness to those who favor a simple metric of well-being can be explained by the fact that, even if it is not regarded as definitive of well-being in its own right, it can be seen as equivalent to a person's own assessment of their well-being, taking into account other aspects [1]. Thus, while most individual measures can only plausibly capture part of the picture regarding well-being, life satisfaction has a reasonable claim to be an indicator of a person's overall well-being. Reliance on life-satisfaction as the sole measure of well-being rests on two assumptions: a) that a score on a life-satisfaction scale accurately reflects a person's assessment of their own well-being; and b) that a person is a reliable judge of their own well-being. Both of these assumptions are open to question. There is evidence that life-satisfaction scores adapt to circumstances, an effect first identified by Brickman, Coates, and Janoff-Bulman [21], and are susceptible to a variety of influences which are arguably unrelated to well-being, such as social comparisons [22] and ethical norms [23]. There is considerable debate about the extent to which these effects undermine subjective well-being measures, if at all [24,25]. In measuring well-being some authors have exclusively focused on subjective indicators. For example, the Australian Unity Well-Being Index measures well-being by merely assessing satisfaction across several aspects of life [26]. SWB, particularly life satisfaction, has been advocated by some researchers as the gold-standard measure for assessing well-being [27]. However, many researchers have criticized this approach as arbitrary, simplistic, and reductive [5,28]. Diener, Inglehart, and Tay [29] point out that ". . . life satisfaction measures have clear limits, and provide only one type of information to policymakers." . In her review of societal well-being variables, Delle Fave [30] concludes that "there is no consensus on which subjective variables could be the ideal and most reliable indicators of well-being" . In the present article, we take the view that, whilst life satisfaction remains a useful measure of well-being, it would be unwise to rely solely upon this single measure and that a broader mix of subjective and objective measures is more appropriate to measure national well-being and quality of life. In fact, there is increasing recognition of the need to integrate hedonic and eudaimonic approaches to well-being rather than relying solely on one and dismissing the other [15,31]. --- Eudaimonic well-being Eudaimonic well-being concerns psychological and social qualities that make a life worth living [32]. Most definitions of eudaimonic well-being exclude emotional components and instead focus on the fulfillment of human potential, psycho-social skills, a meaningful life, and self-actualization [33,34]. Ryff's [35] model of psychological well-being, which includes six key dimensions of autonomy, personal growth, self-acceptance, purpose in life, environmental mastery, and positive relationships, seems to be currently the most dominant in the field of eudaimonic well-being at the individual level of analysis. Other eudaimonic models posit highly similar qualities and skills [36]. The majority of previous global studies on well-being and discussions on the policy implications of well-being have focused on SWB indicators, especially life satisfaction [37]. Eudaimonic well-being measures have been rarely used in global well-being studies and largely ignored in debates on public policy. This seems to be largely due to the fact that comparable multinational data on eudaimonic well-being are only recently beginning to emerge. Huppert and So [31], provided a preliminary examination of eudaimonic well-being based on the data collected in the sixth round of the European Social Survey in 29 European countries. Joshanloo [33] developed a new index of eudaimonic well-being across 166 countries , which makes global studies of eudaimonic well-being possible. Individual-level studies suggest that hedonic and eudaimonic aspects are related, yet distinct components of mental well-being [16]. Joshanloo's [33] results replicate this finding at the societal level. Thus, there is a strong case for including these both hedonic and eudaimonic aspects in holistic models of well-being since they capture different components of human well-being [38] and have differential relationships with other variables [39]. --- Measurement of societal well-being Although most studies of well-being have focused on individual differences, the assessment of well-being at the country level has also flourished over the past few decades [40]. Although it is a widely researched topic in recent years, there is no consensus about the conceptualization and measurement of societal well-being. Different organizations and authors across various fields have proposed an array of dimensions and composite indicators in order to measure progress towards valuable goals and to enable informative and meaningful cross-country comparison [41]. One of the first attempts to measure material and social prosperity via multiple dimensions was made by the United Nations Development Programme , when it introduced the Human Development Index in 1990. The HDI is probably the best known composite well-being index, capturing three dimensions: longevity, education, and income. However, the HDI has received some criticisms ; the main criticism being its narrow definition of well-being and the inclusion of too few dimensions. Thus, a number of alternative approaches to the measurement of prosperity and well-being at the national level have been developed in recent years, in order to capture additional relevant aspects of human wellbeing not included in the HDI. For example, in an effort to select and study quality of life variable in a systematic way, Diener [43] developed a value-based index of societal quality of life, where variables selected for measuring quality of life are reflective of prominent values endorsed across societies. This value-based index of quality of life is grounded on the universal structure of values constructed by Schwartz [44], with two proxy variables measuring each of the seven universal values of hierarchy, mastery, affective autonomy, intellectual autonomy, egalitarian commitment, harmony, and conservatism. The Legatum Prosperity Index, first launched in 2007, measures human progress by assessing nine dimensions: Economic Quality, Business Environment, Governance, Personal Freedom, Social Capital, Safety and Security, Education, Health, and the Natural Environment . The HDI and Legatum Prosperity Index are closely related and reliable measures [47], but although they share approximately 75% of their variance, it has been argued that the Legatum Prosperity Index is a more holistic and comprehensive measure than the HDI [45]. Other examples include the Better Life Index [9,48] and the Social Progress Index , which are available for a smaller number of countries. There are many other models and measures of national well-being . Despite notable differences in approaches to the measurement of societal wellbeing and prosperity, there are also important similarities between different approaches. For example, Phillips [28] provides an integrative review of the societal quality of life models and identifies four common components: civic integration, equal status , sustainability, and social cohesion. --- The purpose of the present study and variable selection Our interest is in how well a nation is doing in a broad range of domains that reflect various aspects of national prosperity and quality of life. An important limitation of previous studies on societal prosperity and well-being is a lack of attention to the factor structure of the indicators at the societal level, typically including a limited range of dimensions, and focusing on the individual level of analysis. By including a wide range of indicators, both subjective and objective, the present study is expected to provide a more comprehensive evaluation of the structure of prosperity at societal level than previous studies. Our primary aim was to reduce the large array of quality of life variables to a smaller number of derived variables. Thus, we factor analyzed the national indicators to identify the underlying factors or dimensions of societal quality of life. As previously noted, there is a wide range of views about which dimensions should be included when measuring prosperity. It is clear that not all aspects can be included in a single study, so every approach to selecting the key dimensions has some limitations. Here, we draw extensively upon both personal and societal well-being research but our sole focus is upon the national, rather than the individual level. Thus, we include both objective and subjective indicators. Our subjective indicators are aggregations of countries' subjective judgments . Many of the indicators we include are calculated based on both subjective and objective data. In addition to our commitment to include both subjective and objective measures, we used three other criteria for the selection of component variables. First, given the emphasis on the complementarity of hedonic and eudaimonic aspects, we intended to include indicators of both aspects of well-being. Second, we were committed to including not only positive wellbeing variables but also negative mental health variables . Grinde [51] argues that the mammalian brain has a positive mood as a default setting, so activation of negative feelings is likely to be the main cause of low well-being. Therefore, negative emotions and mental disorders are as important as positive indicators of well-being. Finally, we only included dimensions available in most countries of the world, to maximize the global coverage of the analysis. Based on these criteria, an initial set of 24 indicators was developed, which are introduced in the methods section and listed in Table 1. Using the data from the Gallup World Poll , we included the SWB measures of life satisfaction , positive affect , and negative affect . We also included the newly developed GWP-based measure of eudaimonic well-being [33]. To complement hedonic and eudaimonic well-being indices from the GWP, we also included: eight dimensions of prosperity as measured by Legatum Institute [45,46]: economic quality, business environment, governance, personal freedom, safety and security, education, health, and natural environment; three proxy measures of mental health: the disability-adjusted life years for depression and anxiety, two frequent mental disorders, and suicide rate; income inequality measured through the Gini Coefficient; globalization measured with the KOF Globalization Index, which assesses three dimensions of globalization: economic, social, and political; friendship opportunities, as an important aspect of social capital and interpersonal relationships. We chose the Legatum Prosperity Index over other prosperity models due to its comprehensiveness , its inclusion of both subjective and objective data, and its wide geographical and time coverage. However, we excluded the social capital index, given its large overlap with the eudaimonic well-being index. Yet, we included as a separate variable a GWP item used in the social capital index to capture friendship opportunities. We also included measures of income inequality and globalization, which are two other important indicators capturing societies' functioning [52][53][54]. It is important to point out that our assortment of variables cover all the important aspects of societal quality of life emphasized in Phillips's [28] and others' integrative reviews of the literature. For example, whereas many models of societal prosperity and well-being have ignored environmental sustainability, we measure sustainability via one of the sub-indices of the Legatum Prosperity Index. The natural environment sub-index measures the quality of the natural environment, environmental pressures, and preservation efforts [45,46]. In addition to examining the structure of prosperity at the national level, the present study also included a number of external variables to establish the nomological networks of the emerging prosperity factors, and examine their discriminant validity. There is ample evidence to suggest that various indicators of well-being have differential associations with other variables. For example, Helliwell, Huang, Wang, and Shiplett [55] found that whereas per-capita income and healthy life expectancy had significant effects only on life satisfaction, freedom and generosity had larger influences on positive affect than on life satisfaction. Diener, Ng, Harter, and Arora [56] found that economic factors were consistently better predictors of life satisfaction than of affective well-being, whereas socio-psychological factors were better predictors or affective well-being than life satisfaction. Corruption at the national level has been also found to be more strongly associated with life satisfaction than with positive and negative affect [57]. Therefore, we expected the emerging factors to exhibit differential relationships with external variables. We expected this analysis, not only to establish the discriminant validity of the emerging dimensions, but also to provide additional insights into the nature of these dimensions. Drawing on prior research, we included a wide range of factors that have been found to affect national well-being, including socio-economic [58], cultural [59], demographic [60] and ecological [61] factors, namely, Hofstede's dimensions of national culture [62], Inglehart-Welzel cultural dimensions [63], religiosity [64], urbanization [65], national age [66], and indices of thermal climate [67]. In selecting the external variables, we were guided by recent major reviews of the literature [68,69]. In sum, we aimed at exploring the factor structure of the 24 prosperity and well-being indicators at the societal level and to establish the nomological network of the emerging factors. The general predictions of the present study were: that prosperity will have a multidimensional structure at the national level, and the indicators would form distinct factors, and that different dimensions would show interpretable and differential associations with the external cultural, demographic, and ecological variables. --- Methods --- --- Measures Variables used in the factor analyses included: life satisfaction , future life satisfaction, enjoyment, worry, sadness, stress, anger, laughter/smile, eudaimonic well-being, friendship opportunities, rest, economic quality, business environment, governance, personal freedom, safety and security, education, health, natural environment, globalization, depression, anxiety, suicide, and income inequality. It is noteworthy that depression, anxiety, suicide, and income inequality were initially used as indicators in factor analysis, yet based on the initial results we decided to remove them from factor analysis and instead use them as external variables. In a replication analysis, we also included life satisfaction these days, happiness, and purpose in life based on items available in older Gallup data. Variables used as external variables to establish the nomological network of the emerging factors included power distance, uncertainty avoidance, individualism, masculinity, self-expression values, secular-rational values, national age, urbanization, heat demands, and cold demands. Gallup-based variables included life satisfaction, future life satisfaction, enjoyment, worry, sadness, stress, anger, laughter/smile, friendship opportunities, rest, life satisfaction these days, happiness, purpose in life, and religiosity. All of the GWP variables are based on data collected between 2007-2012 and 2015-2017. We use 2015-2017 data for our main analyses, and 2007-2012 data for replicating the factor analytic findings. The study also included external variables . All of the external variables refer to the year 2015 , unless otherwise stated below. Eudaimonic well-being. This national index [33] was used to measure optimal functioning. The scores are based on the GWP data and refer to the years 2015-2017 and 2007-2012. This index is composed of seven GWP items measuring learning experience, social support, respect, efficacy beliefs, sense of freedom, and pro-sociality . Other Gallup-based variables. These variables were each measured with a single item. The GWP items used for measuring these variables are shown in S2 Table in the supplementary material. The scores were averaged in each country to construct a national score for that country. Three variables of life satisfaction these days, happiness, and purpose in life were not available in the period 2015-2017, and hence were only used in the analysis based on the 2007-2012 data. National prosperity. Eight out of nine sub-indices of the Legatum Prosperity Index related to 2007 and 2015 [45,46] were used to measure various aspects of national prosperity. The nine "pillars" of prosperity include economic quality, business environment, governance, personal freedom, social capital, safety and security, education, health, and natural environment. Each of the sub-indices consists of dozens of objective and subjective variables. More information can be obtained from http://www.prosperity.com. As some of the items used to build the eudaimonic well-being index have also been used in developing the social capital index, social capital was excluded in this study . It is also noteworthy that the efficacy item used in the eudaimonic well-being index is also used in the business environment subindex of the prosperity index. Some of the affect items have been used to construct the health subindex. However, the health subindex consists of a large number of other indicators, and more importantly in the factor analyses, these affect variables and health were found to load on separate factors. Finally, the freedom item which is used in the eudaimonic well-being index is also part of the personal freedom subindex. Again, the personal freedom subindex consists of a large number of other indicators, and eudaimonic well-being and personal freedom loaded on separate factors. Therefore, we decided not to leave out these crucial variables from the analyses to enable a holistic exploration of these important variables. Globalization. The KOF globalization index [70] related to years 2007 and 2015 was used as a comprehensive measure of globalization, assessing the economic, social, and political dimensions of globalization. Depression and anxiety. The 2015 data from the Global Burden of Disease Study [71] was used to measure the disability-adjusted life years due to anxiety and depression, including years of life lost from premature death and years lived with less than full health. [One DALY "can be thought of as one lost year of healthy life and the burden of disease as a measurement of the gap between the current health of a population and an ideal situation where everyone in the population lives into old age in full health" [72, p. 1579]. The DALY, is a combinatory metric "designed to quantitatively measure the impact of various diseases and conditions on the productivity and well-being of people through a combination of mortality and morbidity estimates" [73, p. 2].] Suicide. The 2015 age-standardized suicide rate was used to measure the prevalence of suicide in each country . Income inequality. The GINI estimates for countries were obtained from the UNU-WI-DER, World Income Inequality Database , which is a database of information on income inequality . All GINI estimates available for each country between the years 2005-2015 were averaged to obtain an income inequality estimate for each nation. Hofstede's dimensions of national culture. Hofstede's four dimensions include power distance , uncertainty avoidance , individualism , and masculinity [74]. The scores for each country were obtained from Hofstede, Hofstede, and Minkov [75]. Inglehart-Welzel cultural dimensions. Scores of self-expression/survival values and traditional/secular-rational values were based on the data from the World Values Survey, Wave 6 . For countries that did not participate in Wave 6, data from Wave 5 was used [76]. National age. In order to measure national age, percentages of the population that are aged 65 and above in each country were used. The data were obtained from https://data. worldbank.org. Religiosity. We used Joshanloo and Gebauer's [77] Gallup-based index of religiosity. This index is calculated as the percentage of people per country who stated that religiosity is an important part of their daily lives. Urbanization. In order to measure the national degree of urbanization, percentages of the urban population in each country in the year 2018 were used. The data were obtained from the world urbanization prospects at https://esa.un.org/unpd/wup/. Temperature. Van de Vliert's [78] indices of thermal climate were used to measure temperature. The hot and cold measures are based on winter and summer deviations from a biologically optimal point of reference . Climatic demands "are operationalized across each country's or region's major cities, weighted for population size, as the sum of the absolute deviations from 22˚C for the average lowest and highest temperatures in the coldest month and in the hottest month" [78, p. 470]. --- Results The analyses started with the main dataset related to 2015-2017. A principal axis factoring with promax rotation was run using the 24 variables . Only 128 countries with complete data were included. Scree plot suggested a 3-factor solution. The factor loadings of this initial model are shown in Table 1. Four variables demonstrated unexpected loadings. Anxiety and depression had positive loadings on the first factor. Income inequality had a positive loading on the second factor. Finally, suicide did not have a substantial loading on any of the factors. We decided to omit these four variables from the factor analysis and instead use them as external variables. This decision was driven by the fact that our aim was to identify unambiguous interpretable factors. In addition, these results cast doubt on the suitability of these variables to measure societal well-being . Thus, to maintain more intuitive factors, these four variables were removed from the analysis and factor analysis was repeated with 138 countries that had complete data on the remaining 20 variables. Again the Scree test suggested a three-factor solution. The results are shown in Table 2. The three factors collectively explained about 68.02% of the variances in the variables. The first factor is loaded by globalization, and all aspects of national prosperity as well as life satisfaction . Generally speaking, this factor represents globalization and modern values, as well as financial and socio-political development, and hence can be labeled as "Socio-Economic Progress". The second factor is dominated by psychological and subjective variables, including eudaimonic well-being and positive affective states. With variables such as smile/laughter, eudaimonic well-being, future life satisfaction, enjoyment, and friendship opportunities, this factor measures a vital and psychosocially rich lifestyle. Thus, this factor can be labeled as "Psycho-Social Functioning". Finally, the last factor is comprised of subjective feelings of worry, sadness, stress, and anger, and thus the factor can be labeled as "Negative Affectivity". Higher scores on the last factor would mean higher levels of Negative Affectivity. --- Replication of factor structure in data from 2007-2012 The same variables were constructed from GWP data collected between 2007 and 2012. The prosperity and globalization variables were related to 2007. As can be seen in Table 3, the emerging factor structure was largely similar to the results with more recent data. The same factors emerged. The 2007-2012 data included three extra variables for a smaller number of countries: happiness, life satisfaction these days, and purpose in life. These three variables were included in a separate factor analysis with a smaller sample size . As shown in Table 4, the same factor structure was replicated. Life satisfaction these days loaded onto Socio-Economic Progress, and happiness and purpose in life loaded on Psycho-Social Functioning. --- Factor correlations and country rankings The consecutive analyses are entirely based on 2015-2017 data. The 20 variables were all z-standardized and averaged to form three higher-level variables of Socio-Economic Progress, Psycho-Social Functioning, and Negative Affectivity. The Socio-Economic Progress score was calculated for nations with a single missing value as well. As shown in Table 5, observed correlations are stronger than latent correlations. In general, however, the correlations are modest, suggesting that a country's standing on one of the dimensions does not strongly predict its standing on other dimensions. S1, S2 and S3 Figs in the supplementary material show the pairwise relationships between the variables. A three-dimensional scatterplot is shown in Fig 1 . Cronbach's alphas for each of the three variables based on the standardized variables are reported in Table 5, indicating acceptable internal consistency for each of the variables. Table 6 presents national scores and rankings. --- Regional distribution of national prosperity and well-being --- The nomological network of the three dimensions Table 7 presents the correlations between the three prosperity variables and the external variables of the study. The correlations with the four variables removed from the factor analysis are also presented in the table. As can be seen, most of the variables have differential associations with the external variables. This suggests that the variables have partly unique nomological networks. --- Discussion Based on the results of the factor analysis, we identified three interpretable factors suggesting that, within the complex picture presented by the wide range of available indicators, distinct concepts are discernible. Below, we elaborate on the nature of the three factors. --- Factor 1: Socio-Economic progress This factor is loaded by variables that mostly reflect external conditions of life , country-level situations, and the functioning of public, social, and political institutions. Globalization and all of the prosperity sub-indices loaded on this factor. The indicators of this factor are partially based on people's opinions as expressed in large-scale surveys, with survey questions mostly capturing people's opinions about the socioeconomic situations around them. The variables loading on this factor are primarily dependent on economic growth. Surprisingly, life satisfaction too loaded on this factor, as its only purely subjective indicator. Cantril's ladder of life has been shown to be more closely associated with socio-economic indicators than standard single-item life satisfaction measures [50]. However, in our supplementary analysis, we found that satisfaction these days also loaded on Factor 1 . Unlike other subjective indices , national life satisfaction does not seem to reflect well how life is subjectively experienced on a day-to-day basis. Instead, it seems largely to reflect how people perceive, or are affected by, economic and socio-political developments in their nations. This finding is consistent with evidence that economic, political, and social stress at the national level can lead to rather rapid declines in a nation's level of life satisfaction [40,79,80]. Life satisfaction can be seen as an indicator of the extent to which people are getting what they want in life. Our results suggest that, when people's satisfaction responses are aggregated to calculate national scores of satisfaction, they align well with countries' objective levels of development. Previous research has also found strong correlations between national life satisfaction and economic and prosperity indicators [33,40,81]. Thus, it can be surmised that life satisfaction questions encourage people to think of their lives in economic terms [82]. This raises the question whether the overlap between country-level life satisfaction and Socio-Economic Progress is sufficient to create redundancy such that the simultaneous use of socio-economic indicators and life satisfaction at the country level adds little benefit, or worse, causes issues of multicollinearity . This large overlap also suggests that the availability of reliable measures of socio-economic development for a country may reduce the need for relying on life satisfaction measures, if the outcome variable of interest is Socio-Economic Progress. Conversely, however, given its strong loading on the first factor, national life satisfaction could be considered as a valid and highly useful summary index of general socio-economic development in large groups . This is particularly so at the community or group level , where reliable group-level indicators may be nonexistent. --- Factor 2: Psycho-Social functioning This factor is more subjective than Factor 1, being loaded by positively-valenced mental states as well as eudaimonic well-being and friendship opportunities. In the additional analysis, we found that happiness and purpose in life also loaded on this factor. These variables have in common an emphasis on inner feelings, psychological and interpersonal resources and functioning in life rather than external living conditions. This factor also covers social domains of well-being including altruism and social capital. In sum, this factor reflects a version of well-being that emphasizes living a worthwhile, hopeful, and enjoyable life involving pleasant states of mind but also developing and exercising personal and social skills. Our finding that life satisfaction loaded on Factor 1 but affective variables loaded on other factors resonates with previous research concerning differential results for life satisfaction and positive affect. Earlier studies have found that national happiness is not correlated with life-satisfaction [83], and that affective measures are more sensitive to circumstances that evoke positive and negative emotions and less so to socioeconomic status, economic conditions, income, and material variables [84][85][86][87]. The fact that life satisfaction measures loaded on Factor 1 and happiness loaded on Factor 2 suggests that different conclusions can be drawn using different SWB measures, and that findings produced by one measure might not hold for other measures. Thus great caution is needed when comparing the results of studies using different measures of well-being [88]. An important finding is that the present and future life satisfaction loaded on different factors. Gallagher, Lopez, and Pressman [89] argue that future life satisfaction measures the expectation of positive future outcomes and thus is a face-valid measure of optimistic expectations for the future. At the individual level, future life satisfaction has been found to have a stronger correlation with optimism and hope than do present and past satisfaction [90,91]. The present country-level results are in keeping with the previous results. Our results show that, compared with present life satisfaction, future life satisfaction is associated less strongly with current socio-economic conditions and more strongly with positive affect and eudaimonic well-being. These results suggest that, at the country level, future life satisfaction is more likely to measure positive emotions and attitudes such as hope and optimism than evaluations of objective living conditions. Given the dearth of country-level studies involving future life satisfaction, these explanations and suggestions need to be further investigated in future studies. Yet, our findings do clearly indicate that future and present life satisfaction are distinguishable in interpretable ways, which needs to be acknowledged in future research. We found that eudaimonic well-being also did not load on socio-economic prosperity. This too is consistent with previous research [33,92]. The present results and previous research [93] leads us to predict that eudaimonic well-being is less likely than life satisfaction to change rapidly in response to economic and political stress at the national level, a prediction to be tested empirically in future research. --- Factor 3: Negative affectivity Of the three, Factor 3 is the most homogeneous: sadness, worry, stress, and anger, are all negatively-valenced affective states, and can be broadly categorized as forms of displeasure. Hence, this factor captures individuals' day-to-day experience of unpleasant affect, and thus can be considered a measure of ill-being. However, it can be transformed into a positive well-being measure if reverse-scored. Whereas the separation of Factor 1 from the other two factors is interpretable in view of the level of subjectivity of the indicators concerned, the distinction between Factors 2 and 3 is not based on the levels of subjectivity but on the valence of the subjective states. This distinction is consistent with the predominant view that positive and negative affect are largely independent of each other, rather than two sides of the same coin [94]. Grinde [51] argues that this distinction is particularly important in that positive and negative affect have differential associations with one's overall level of functioning. Helliwell et al. [55] showed that positive emotions were more strongly associated with life satisfaction than were negative emotions and that positive and negative affect had differential relationships with other variables . Our results indicate that, at the country level, positive affect is more strongly associated with eudaimonic well-being, future satisfaction, happiness, friendship opportunities, and feeling well-rested than is negative affect. Our results converge with the previous results in suggesting that positive and negative affect capture two different aspects of country-level well-being and should be studied independently. --- Nomological networks The three factors showed clearly distinct nomological networks. Below, we highlight some of the findings related to each of the factors. Factor 1: Socio-Economic progress. This dimension was correlated with all of the external variables, except suicide and uncertainty avoidance. The strongest correlations were with national age , religiosity , self-expressive values, and individualism. This pattern is consistent with the general expectations of socio-economic development. For example, developed countries tend to have older populations, and endorse more secular and individualistic values [95]. The factor has a positive correlation with cold demands and a negative association with heat demands. It is also correlated with anxiety and depression. People in richer countries are less likely to report that their lives have a meaning [92], which may contribute to higher levels of depression. Research has also found that richer countries are also more likely to have a higher prevalence of some health problems such as obesity, and alcohol use [96][97][98]. Therefore, a high level of Socio-Economic Progress is not a panacea, and these countries still have challenges to face. It is not clear whether these challenges are products of higher Socio-Economic Progress or remnants of pre-existing problems that Socio-Economic Progress has not yet been able to solve; or whether rising levels of Socio-Economic Progress will resolve these issues, intensify them, or leave them unaffected. Factor 2: Psycho-Social functioning. This factor had relatively weaker correlations with the external variables than the other two factors, which reflects its strongly subjective content. It has its strongest correlation with self-expressive values, other correlations being nonsignificant, weak, or moderate. Unlike the other two factors, it had no association with temperature. This pattern of associations suggests that societies with higher levels of Psycho-Social Functioning are more likely to emphasize subjective quality of life and self-expression over economic and physical security [95], and are open to situations that are novel, unknown, and different from usual [75]. We speculate that Psycho-Social Functioning's orthogonality to suicide as reflected in the multidimensional plots is largely a result of its association with meaning in life. A strong endorsement of self-expressive values is one of the main commonalities between countries that are high both on Socio-Economic Progress and Psycho-Social Functioning. Finally, Psycho-Social Functioning has a weak but significant positive correlation with anxiety. Psycho-Social Functioning's weaker associations with secular/individualistic values as well as economic and political situations suggests that developing countries are more likely to score well on this type of well-being than on Socio-Economic Progress. This is reflected in the fact that some African countries which suffer from life dissatisfaction have better standings on eudaimonic well-being . Factor 3: Negative affectivity. This variable has weaker associations with the external variables than Socio-Economic Progress. Its strongest correlation is with secular values , religiosity , and cold demands . The pattern of correlations for this variable suggests that negative affect is higher in more collectivistic, hotter, less urbanized countries, countries with younger populations and higher levels of uncertainty avoidance, power distance, and income inequality. This suggests that negative affect is inversely associated with socio-economic development and the endorsement of progressive values. --- Dimensionality of national quality of life Our data-driven exploratory analysis provides a plausible framework for understanding and appraising quality of life at societal level, and supports the view that country-level quality of life is a multidimensional construct, not a holistic entity that can be measured adequately by a single measure. Our two-dimensional plots of variables do not provide evidence of centrality for any of the variables. Our results are consistent with Diener and Suh's [13] conclusion that objective, and subjective indicators are complementary, each capturing different aspects of societal well-being, and thus should be used in parallel. Therefore, it is necessary for future research to study the three dimensions separately as well as in tandem. Quality of life of a given country differs substantially depending on the measure used to operationalize it. For example, the use of objective measures of material wealth may produce different rankings from measures of social and psychological resources [56,99]. Similar findings were observed in the present study. All the countries that ranked in the top ten on the Socio-Economic Progress dimension are affluent countries from Nordic, Anglo, and Western-European societies. On the other hand, the top 10 countries in the psychosocial functioning dimension are more diverse , as are the 10 countries that rank lowest in Negative Affectivity . Our regional analysis also shows the importance of considering the dimensions separately. Whilst the pattern of high and low scores across different regions was broadly similar between Socio-Economic Progress and Psycho-Social Functioning, South and Southeast Asia, Latin America and Sub-Saharan Africa scored higher on the latter than the former, whereas the reverse was true of European, Commonwealth of Independent States and Middle Eastern countries. Comparing Negative Affectivity with the other two factors revealed some more marked differences. Commonwealth of Independent States and East Asian countries had much better scores on this factor than the other two ; Northern America rather worse. These differences underline the complexity of prosperity and well-being at the national level. The fact that certain countries scored better or worse on Socio-Economic Progress than the other factors suggests that the aspects of prosperity which make up this factor do not tell the whole story of what influences well-being at the national level. Some countries, such as Nigeria and Paraguay, scored markedly better on Factors 2 and 3 than Factor 1 . Therefore, a nation's standing on one dimension may not accurately reveal its standing on the others. These findings militate against a reductive and simplistic approach that assumes a single gold standard measure of quality of life. Our results unmistakably indicate that using a single measure of national prosperity is inappropriate and may lead to simplistic conclusions. Although positive and negative affect along with life satisfaction tend to form a SWB factor in studies on individual-level indicators of well-being , in our national level analysis, these variables loaded on three distinct factors. Thus, conclusions about the structure of well-being obtained at the individual level should not be automatically translated to assumptions about the structure of prosperity and well-being at the national level. An interesting finding was that Socio-Economic Progress and Psycho-Social Functioning had a stronger correlation than Psycho-Social Functioning and Negative Affectivity . In general, the Negative Affectivity factor is more distinct from the other two factors. This finding is difficult to explain given that negative affect has been rarely studied at national level and not much is known about it. Yet, the finding is consistent with Helliwell et al.'s [55] findings suggesting that negative affect is less fully explained by other well-being and prosperity variables than are life satisfaction and positive affect, and is less strongly associated with life satisfaction than positive affect is. In sum, these results are suggestive of both complementarity of and overlap between the three dimensions. --- Anxiety, depression, suicide, and income inequality The four variables of anxiety, depression, suicide, and income inequality are considered by some as important components of country-level quality of life [28,52]. For anxiety, depression, and suicide, these assumptions seem to be largely based on individual-level findings. For example, a depressed and anxious person is almost certainly not very happy. Yet, we found that, at the national level, these variables do not connect with the other indicators in an expected manner, which may cast doubt on their utility in measuring national quality of life . Depression had a positive loading on Factor 1, and its loading on Factor 3 was almost zero. Yet, it had a weak negative loading on Factor 2, which is consistent with the general expectations, since this factor involves variables such as meaning in life and positive affect that are antithetical to depression. Anxiety also had an expectedly positive loading on the first factor, and a loading in the expected direction but weaker on Factor 3. Given these mixed results, it is doubtful that depression and anxiety can be used as unambiguous indicators of national quality of life. Instead, we suggest using depression and anxiety as indicators of quality in life in depressed and anxious populations in a given country, as vulnerable populations that deserve special care. It is worth noting that we used the DALYs due to anxiety and depression , which are incidence-based measures that combine both mortality and morbidity into a single value [73]. Alternative national measures of anxiety and depression may lead to different conclusions. Surprisingly, suicide had a weak but nontrivial negative loading on Factor 3, and trivial loadings on the other factors. Some previous studies have also found positive correlations between suicide rates and SWB [100,101]. The suicide rate has been excluded from the most recent update of the Social Progress Index due to low correlations with other indicators of health and wellness [102]. Daly et al. [100] suggest that personal unhappiness may be at its worst when surrounded by those who are relatively more content with their lives. Diener and Suh [13] suggest that in high-SWB and high-income countries, there may be less social support and security when life goes badly as well as higher chances of loneliness which may lead to higher rates of suicide. In other words, higher levels of freedom in these countries have both the desirable effect of increasing SWB and the undesirable effect of increasing the possibility of suicide for people whose lives go badly. Based on these findings, national suicide rates cannot be used as an unambiguous nation-level quality of life indicator, and instead could be used for monitoring the status of people with suicidal tendencies and other affected populations in any given country. Income inequality has shown positive, negative, and ambiguous associations with SWB [40,103]. There is evidence that inequality may increase well-being in some nations but not others [104][105][106]. Similarly, inequality's association with economic growth is also not clear-cut [107]. We also found mixed results for income inequality. It had a negative loading on the first factor, and surprisingly a positive loading on the second factor. Therefore, our results dovetail with the previous evidence in suggesting that income inequality is not an unambiguous indicator of national quality of life. Therefore, we suggest not including income inequality as an indicator of country-level quality of life. Instead, income inequality could be studied in its own right as an important nation-level variable that can have complex and heterogeneous relationships with various aspect of national quality of life in various contexts and groups. In view of the mixed pattern of associations with the other indicators, we excluded these variables from our factor analysis and instead used them as external variables to establish the nomological networks of the quality of life variables. We acknowledge that theory-driven treatments of national quality of life may be more open to including these four variables as component parts, yet, our data-driven approach hinders this on the grounds of the ambiguous factor analytic and correlational findings for these variables. --- Relevance to public policy This paper was intended to investigate holistically the structure of prosperity and well-being at the national level rather than to directly inform public policy. Nevertheless, we do believe that our findings would be of interest to policy makers. For example, the fact that our results support a broadly-based approach to measuring well-being, involving a mix of subjective and objective measures and avoiding over-reliance on any single type of measure is relevant to national well-being programmes as well as to academic research. In addition, the performance of nations varies across the three factors, so that a nation's standing on one dimension does not reveal its standing on the others. This clearly cautions against over-reliance on unidimensional means of improving well-being-for example, an exclusive focus on economic prosperity. Thus, our results provide a comprehensive and multidimensional picture of well-being to inform the development of public policy. We hope that future studies will build on our work to provide results of more direct relevance to specific policy issues. For example, future studies might consider factor-analysis on sub-categories of measures organized by different policy objectives rather than across the full range. --- Limitations and future research Some of the limitations of this study need to be mentioned. First, the choice of indicators affects the results of factor analysis. The obtained factor structure in any factor analysis is inevitably contingent on the selected variables. Our selection of variables of national well-being is of course not definitive. Other subjective and objective indicators of national well-being could be incorporated in future studies on the structure of human well-being at the national level, to see if conclusions are affected in significant ways. As new scientific methods and data sources for measuring well-being at the nation level are emerging , future studies can include more measures of wellbeing from diverse sources. Second, the GWP has its limitations, e.g., the single-item measures used to assess most of the concepts. Future research will need to use more reliable measures. Subjective measures of quality of life have been criticized on various grounds, including equivalence in translation and psychometrics [109,110]. For example, researchers have emphasized that to make meaningful cross-cultural comparisons, equivalence and bias need to be addressed in cross-cultural surveys [111,112]. More research in this area is needed to examine the magnitude of the effect of these artifacts on the measurement of well-being across cultures. Third, we used a limited number of external variables to validate the structure of national wellbeing that emerged in the present study. Future studies could include additional predictors or outcomes of well-being such as progressive taxation, personality traits, and crime rates . Fourth, given the cross-sectional nature of our data, causality may not be inferred and future research needs to use longitudinal research designs to shed light on the direction of causality. Finally, cross-national comparisons and ranking of countries are subject to a variety of caveats, which deserve special attention. The ranking of nations against the three factors: Factor 3 in particular-produced some surprising results. For example, whilst Iraq and Syria, which have endured bloody internal conflict, had the highest levels of negative affect, Somalia, a country experiencing similar strife, had one of the lowest. The predominance of former Soviet countries among those reporting the lowest levels of negative affect is also difficult to explain. We acknowledge that these-and perhaps other-results may have been influenced by other factors affecting the responses as well as by actual levels of negative affect. As argued by Tov and Au [113] cross-national differences in well-being and country ranking on well-being variables need to be interpreted with caution. The equivalence of meaning of SWB concepts should be carefully inspected in studies aimed at comparing countries on well-being measures, because these terms might mean different things to individuals from different cultures. For example, previous studies have found that meanings of, and attitudes to, terms such as "happiness" and "life satisfaction" may vary across languages and cultures [110,[114][115][116]. Therefore, a necessary avenue for future research would be to tease out cultural influences systematically. --- Concluding remarks The limitations of GDP and similar wealth indicators have led to the development of numerous ideas and frameworks to measure national quality of life and provide information relevant to public policy. SWB, particularly its cognitive component has received extensive attention in this area of research and practice. Our results expanded these insights in various ways. For example, we found that, in comparison to life satisfaction, the affective components of SWB reflect information that is more likely to be different from that already captured by economic indicators. Moreover, our results on the structure of prosperity and wellbeing variables provide a systematic way to look at the diverse indicators and their interrelations. For example, the results suggest that eudaimonic well-being has stronger associations with positive affect than life satisfaction and Socio-Economic Progress, and eudaimonic wellbeing is also more likely than life satisfaction to provide information that is different from economic indicators. Our results also call into question the practice of categorizing affect and life satisfaction under the title of "subjective well-being" at the country level. This conceptualization stems from individual-level results and we showed in this article that it was not consistent with country-level results. Delle Fave [30] highlights the current need for a more integrated and articulated perspective in the selection, use and interpretation of well-being indicators. One way to make progress towards satisfying this pressing need is data-driven explorations of the factor structure of the societal indicators of quality of life. Our study seems to be the first broad and inclusive study of this sort, aimed at organizing a large list of indicators in a conceptual structure. Inquiry into the structure of well-being at the national level is of crucial importance at this stage of development in this field of research. The results of such studies can help us avoid over-reductionism, and instead enable a systematic identification of elementary indictors to efficiently reduce the number of variables. Such studies help to balance the hegemony of particular approaches over others [117]. They can also support the development of empirically-informed conceptual frameworks. It is, however, appropriate to be cautious at this stage, in view of the fact that this study is among the first factor-analytic studies of prosperity and well-being at the country level. Thus, our findings should be considered preliminary. It is hoped that these results will stimulate more research endeavors aimed at clarifying the structure of national prosperity and well-being. It is noteworthy that studies of this nature involve ecological analyses the results of which do not necessarily have implications for individuals [83]. In conclusion, the results of our research paint a complex and promising-if provisionalpicture of prosperity and well-being at the national level. The complexity of the relationships between the three well-being factors, and between them and other variables, underlines the need for a broadly-based approach to the measurement of well-being, avoiding over-reliance on any single indicator such as life satisfaction. We hope that other researchers will carry out further work to expand and advance these findings. --- This work was supported by the Ministry of Education and the National Research Foundation --- All relevant data underlying the results of this study that come from the Gallup World Poll can be purchased from Gallup at the following link: https://www.gallup. com/home.aspx. The authors did not have special access privileges. Data from sources other than Gallup are publicly available and can be obtained from original sources. Detailed information about these data and their sources are provided in the Methods section. --- Supporting information S1 --- S3 Table. Intercorrelations between the 24 indicators. --- S4 Table. Global regions . --- --- Data curation: Mohsen Joshanloo. Formal analysis: Mohsen Joshanloo. Funding acquisition: Mohsen Joshanloo. --- Methodology: Mohsen Joshanloo. Writing -original draft: Mohsen Joshanloo, Veljko Jovanović. Writing -review & editing: Mohsen Joshanloo, Veljko Jovanović, Tim Taylor.

Social scientists have been interested in measuring the prosperity, well-being, and quality of life of nations, which has resulted in a multiplicity of country-level indicators. However, little is known about the factor structure of these indicators. We explored the structure of quality of life, using country-level data on tens of subjective and objective indicators. Applying factor analysis, we identified three distinct factors that exhibited both overlap and complementarity. This structure was replicated in data from previous years and with a partially different set of variables. The first factor, 'socio-economic progress', is dominated by socio-political and economic indicators but also includes life satisfaction, which thus appears to reflect objective living conditions. The second factor, 'psycho-social functioning', consists of subjective indicators, such as eudaimonic well-being and positive affective states. The third, 'negative affectivity', comprises negatively-valenced affective states. The three macro-factors of societal quality of life demonstrated moderate intercorrelations and differential associations with cultural and ecological variables, providing support for their discriminant validity. Finally, country and regional rankings based on the three societal factors revealed a complex picture that cautions against over-reliance on any single indicator such as life satisfaction. The results underline the need for a broadly-based approach to the measurement of societal quality of life, and provide an empirically-derived multidimensional framework for conceptualizing and measuring quality of life and well-being at country level. This study is thus an initial empirical step towards systematizing the multiple approaches to societal quality of life.

Introduction An unintended pregnancy is a pregnancy that is mistimed, unplanned, or unwanted at conception [1,2]. Representing the unmet need for family planning, it is a public health issue at the core of women's fertility and their reproductive freedom [3]. Unintended pregnancy results in significant societal costs and poor maternal and child health outcomes [4][5][6][7][8]. International calls for the development of indicators that measure the ''unmet need for fertility regulation'' have advanced the issue as a matter of sexual health rights [9]. Given the consequences that families face from unplanned births and unsafe abortions, preventing UP is an international health priority [9,10]. Since 2010, the universal right to effective family planning forms part of the 2015 United Nations Millennium Development Goals, in line with the International Conference on Population and Development in Cairo, and the World Health Organization [9,11]. Importantly, unintended pregnancies also form part of the widening gap of health disparities affecting vulnerable women like undocumented immigrants [12][13][14][15][16]. Today, it is estimated that up to 3.8 % of the Swiss population is not documented, a proportion that is similar to that of the United States [17]. Despite being a small country, Switzerland has become a common transit and destination point for migration from all over the world; contributing factors being the poor global market, Switzerland's central location in Europe, and its multiple official languages. However, the country's strict visa and asylum policies make undocumented immigration a reality for most migrants. An estimated 8,000-12,000 undocumented migrants live and work daily in the city of Geneva alone [18,19]. Although these populations may purchase health insurance regardless of status, they are often limited by the demanding premiums of Swiss plans [12]. Furthermore, existing health burdens are magnified by language barriers, cultural stigma, precarious social support networks, lack of awareness about available health resources, and continued fear of immigration authorities, all of which limit undocumented immigrants' ability to effectively access care in this setting [14,16,[20][21][22]. Notably, it has already been demonstrated that undocumented women in Geneva have particularly low rates of primary care and poor knowledge of birth control [12,13,23], likely putting them at risk for unintended pregnancies. Following in the direction of these international health guides, and health disparities agendas in the industrialized world that explicitly address increasing rates of UP [3,4,8,24], Geneva health institutions have begun to focus on risk factors for unintended pregnancies, particularly among the waves of new immigrants. Our specific aim was to examine the effect of undocumented status on UP among women presenting at a Swiss public hospital in Geneva. This is a novel analysis, and the first of its kind in Switzerland, as no other database exists that asks about UP among women residing in Switzerland. --- Methods --- Participants, Data Collection This secondary data analysis uses cross-sectional data collected from pregnant women who presented to the women's University Hospital in Geneva from February 2005 to October 2006. The data is part of a broader study on women's health [13] supported by the ''Migrant Friendly Hospitals'' project in the Swiss federal office of public health, which promotes research towards the development of Swiss healthcare centers that are skillful in cross-cultural care [25]. Only women with plans to reside in Geneva were included in the study. As part of the broader study protocol, case managers and social workers contacted/visited with questionable cases, to insure that tourist patients were excluded from recruitment. Women who were unable to provide informed consent or who decided to have a voluntary termination of pregnancy were also excluded from the pregnancy study. Participants completed a questionnaire in face-to-face interviews with midwives during the initial pregnancy consultation and/or follow-up. All participants were provided written informed consent prior to joining the study. Ethics approval for the study was obtained through the University of Geneva Institutional Review Board . --- Measures The dependent variable of interest in this study was UP. To capture intention of the current pregnancy, women were asked whether their pregnancy had been ''planned'' or ''accidental''; ''accidental'' was defined as ''unintended'' for these analyses. The main independent variable was documentation status. All women were asked whether they had legal permission to reside in Switzerland, to which they could reply ''yes'' or ''no.'' Women who responded ''no'' were counted as undocumented in Switzerland. We examined the effect of undocumented status on UP, and the effect of other predictors: socio-demographics, family interaction, health services utilization, violence exposure and psychological trauma, in multivariate models. Potential covariates were selected based on previous study findings regarding UP and significant predictors, particularly among vulnerable populations. This list was pared down to 17 variables: using variables with over 75 % data present for both undocumented and documented women, and accounting for power, and sensitivity tests . Selected socio-demographic covariates were age, marital status, whether the woman was employed and whether her living quarters were comprised of more than one room . Family interaction or social support factors included whether the respondent had a stable relationship with the man responsible for the current pregnancy, if she had a family member in Geneva, and whether she had children. Health service utilization variables included if she ever had a cervical cancer screen, whether she took medications, and whether she was using contraception at conception. Women who did not use contraception were classified as ''nonuser'' versus any type of contraception. Other health service covariates were: history of any voluntary TOP and knowledge of emergency contraception. Drug use addressed using tobacco and other substance use. For violence, women were asked if they had been exposed to any form of violence in their lifetime. We also included respondents' reported psychological trauma: past treatment for a psychological disorder and if currently under any treatment for a psychological disorder. --- Statistical Analysis We obtained descriptive statistics of the study sample of 394 women who completed the questionnaire, in relation to all our variables of interest. Using Chi square exact tests, we compared the proportion of UP between documented and undocumented women. We used simple logistic regression to examine all variables' association with UP. We then used multivariate logistic regression to examine whether undocumented status was associated with UP after stepwise adjusting for the described variable groups. We also performed stratified analyses to examine significance of these factors with UP, among undocumented and documented women alone. We present odds ratios with 95 % confidence intervals of the unadjusted and adjusted estimates. Significant results are at the p B 0.05 level. Out of the 394 women whose data were included in these analyses, 76 % had complete responses for the study variables included in the final model. The following variables had the highest missing data rates: stable relation with newborn's father , single room apartment , family in Geneva , has child and knowledge of emergency contraception . Although the quantity of these missing variables was higher among the undocumented women, overall patterns of missing variables were randomly distributed among the observations, thus we proceeded with list-wise deletion of observations with missing data. The analysis retained 298 observations for all regression models. We used Stata version 12 for our analyses. --- Results Out of 409 women who were invited to participate, 394 accepted . Of these women, 161 were undocumented immigrants . Nearly all of the undocumented women in our study sample were from Latin America, and they were all uninsured. Undocumented women had a higher proportion of UP . Undocumented women had a lower mean age of 29.4, versus 31.1 for the documented women. In terms of sociodemographics, there were stark differences: 72.5 % of documented women were married while only 20.5 % of Examining health services, all of the documented women had received a cervical cancer screen at least once in their lifetime, compared to 13 % of undocumented women who never had a pap smear. While 57.4 % of undocumented women did not use contraception when they became pregnant, 83.2 % of documented women were not using contraception. However, on follow-up questioning on ''reason for no-contraception'' among the non-users, 48.5 % said they wanted a baby and 5.6 % said they wanted a baby at the present moment. Therefore, over 50 % of the women not using contraception did so purposefully because they desired pregnancy-this pattern was more prevalent among the documented women with 177 out of 193 documented contraception non-users expressing a pregnancy desire in follow-up questions. In comparison, 34 out of 85 undocumented contraception non-users expressed this desire. Notably, 61.2 % of undocumented women had no knowledge of emergency contraception as a possibility while only 9 % of documented women lacked this knowledge. With regards to drug use, more documented women used tobacco in their lifetime, and other substances. There were no significant differences with regards to violence or psychological trauma. Table 2 shows that undocumented status was associated with UP even after adjustment . Having a stable relationship with the father was the only family interaction variable that remained significant . For health services utilization factors, contraception non-use was protective against UP, and remained significant after adjustment . Given that different modes of contraception were grouped, we checked the distribution of UP among each type of contraception, to see if contraception type made any difference : 0 %; depoprovera : 100 %; diaphragm : 100 %. The percentages of UP ranged from 83 to 100 % for all forms of contraception types among undocumented women and 50-100 % for all contraception types among documented women. Thus, among all women and in stratified analysis, using any contraception mode indeed increased the odds of UP, versus nonusers . Insecure contraception was defined as condom, retraction or calendar. When examining users of contraception , there was no difference in insecure contraception usage between documented and undocumented women . Furthermore, when comparing those who used insecure contraception versus those did not use insecure contraception, there was also no significant difference in UP rates-among all women: 92.9 versus 86.2 %; undocumented alone: 91.9 versus 95.8 %; documented women alone: 76.2 versus 88.9 %. Having a history of voluntary TOP decreased odds for UP after adjustment . Current treatment for a psychological disorder was protective , while past treatment actually increased odds for UP . --- Stratified Analyses To fully examine the effect of these covariates on UP, and given the potential for interaction between documentation status and covariates, we also performed stratified analyses . Among the undocumented women, the following variables significantly decreased the odds of UP after adjustment: contraception non-use , medication use , history of voluntary TOP and being under any current treatment for psychological disorder . Among the documented women, after adjustment, contraception non-use remained significant . Past history of psychological treatment increased the odds of UP . --- Discussion Undocumented status increased the odds of UP despite controlling for known risk factors that disproportionately affected the undocumented women in this study. Similar associations with UP have been found among recently migrated women in the United States [20]. The increased odds for UP can be partially explained by the social burdens that limit immigrants' ability, especially undocumented immigrants, to access effective contraception services [16,26]. Nevertheless more work remains in explaining the complex relationships connecting the numerous predisposing risks that place undocumented women at risk for UP. Past treatment for a psychological disorder increased the odds for an UP, also calling attention to this group. The association with psychological issues is well documented, with UP being linked to depression, intimate partner violence, household trauma, a history of abuse and a history of non-consensual sexual debut at age 15 or younger [20,[27][28][29]. Interestingly, women currently under any treatment for psychological disorder had decreased odds for UP, possibly reflecting an ongoing access to health services, which could predispose to an access to family planning [30][31][32]. Indeed, we found that factors linked to health utilization were protective. This conclusion was reinforced when we examined undocumented women alone in stratified analyses and found that taking medications, a history of voluntary TOP, and currently receiving treatment for a psychological disorder, all decreased the odds of UP. As expected, having a stable relationship with the father of the newborn decreased odds for UP among all women, although this finding was not statistically significant in stratified analyses. However, studies of women's reproductive practices have repeatedly shown that partners play an important role in family planning choices, such as utilization of contraception, attitudes surrounding pregnancy intentions, and decision-making regarding pregnancy options [33]. This also coincides with literature showing that unintended births are more common among single women and women not living with their partners [20]. In one study among the urban poor, partner status was the strongest predictor of UP, increasing the risk 2.5-fold for single women [34]. Notably though, women who are poor, have a lower education level, and who are undocumented are also less likely to have domestic stability, plan reproductive choices effectively with their partner, or be married-prominent factors which all affect risk for UP [2,14]. We found that contraception non-use decreased the odds of UP among all women and in stratified analyses. Using any contraception mode increased the odds of UP, versus nonusers. While this was somewhat unexpected, a 2012 Guttmacher brief did show that American women who used contraception inconsistently or incorrectly accounted for 43 % of all unintended pregnancies [1]. It is estimated that in the United States and France, 50 % and 65 % of women, respectively, report this as the reason for an UP [26,35]. Unfortunately, we did not have information about the frequency or effectiveness of contraception use for women using contraception [32,36,37]. Use of ineffective contraceptive methods like condom and non-hormonal approaches, insecure contraception such as calendar and retraction methods, and/or frank misuse of contraception is linked not only to socio-demographic factors that affect knowledge and reproductive self-efficacy, but also to ambivalent attitudes about pregnancy planning [35,38]. Although in this study we did not find a difference in UP between users of insecure contraception and secure contraception, the high rates of insecure contraception among all women who were contraception users distributes focus to the need for the teaching of effective and correctly utilized methods in these populations, and for delving into why women prefer certain contraceptive approaches. In Switzerland, insecure methods do not cost much while more reliable methods are expensive and not provided for free . In fact, most insurance companies in Switzerland do not even cover the prescription costs for contraception. In the study's clinic setting, women are eligible for free or reduced full-spectrum contraception services, depending on a financial sliding scale. Despite considerable progress, there is much to learn about contraceptive use [2]. We also propose a more technical explanation for the unexpected contraception-use finding. As stated in the results, on follow-up questioning among the non-users about why they did not use contraception, over 50 % of the women not using contraception expressed some desire for pregnancy-this pattern was more prevalent among the documented women. Admittedly, this added information confounds the interpretation of the contraception variable, but adds further credence to our discussion above about pregnancy attitudes affecting contraceptive use and choices. There are of course limitations to this study. Because this is a cross-sectional study, causation cannot be assessed. As well, it is difficult to present our results in light of any population-based indices for UP in Switzerland, as there are none. Estimates for Swiss unintended pregnancies are based on surveys from neighboring European countries, with Western Europe at 32 % [39]. Despite a small sample size, we had a high participation rate for the study. Two variables that we would have liked to account for include insurance and race/ethnicity. However, insurance and race/ethnicity were co-linear with documentation status, making it difficult to distinguish the effects of these variables from the primary predictor. As this was a secondary data analysis, our variable selection was limited to the availability of information that had already been collected. For example, data was not originally collected from women who intended to have abortions, and thus these cases were not included in our analyses. Another example is the description of UP used in this study. Pregnancy unintendedness is not an easily definable concept, and its exact meaning has been extensively reviewed and critiqued in methodological and sociological literature over the years [2]. The National Survey of Family Growth in the United States states that there is ''a spectrum of intendedness, including ambivalence, and defines UP to include mistimed , unplanned, or unwanted pregnancy'' [2,40]. The original survey asked women whether their pregnancy had been ''planned'' or ''accidental.'' We took ''accidental'' to mean ''unintended'' for these present analyses: our definition of UP was simplistic in this scope. Although these results are based on 2005-2006 data, there is no other Swiss dataset that has asked about UP thereafter. Finally, since survey data was collected by faceto-face interviews, women may have responded differently given a social desirability bias or a stigma regarding UP. Yet despite the data limitations, our findings demonstrate that even in a small, well-controlled, and wealthy country like Switzerland, undocumented women continue to bear a significant risk for UP. --- New Contribution to the Literature This analysis is important and unique as it is the only study that inquires about UP among women in Switzerland, and one of the few studies that directly links UP to immigrant documentation status. Undocumented status was significantly associated with UP, even after adjusting for other significant and well-recognized risk factors. These findings highlight the tremendous risk of undocumented status on UP. The high rates of insecure contraception observed among all women, and the association between contraception use and UP, also distributes focus to the need for the teaching of effective contraceptive methods. Public health systems in countries caring for incoming immigrants must make strides to ensure that all patients are counseled about family planning at any and every health visit -for the sake of diminishing the disparities that limit the reproductive freedom of women.

Unintended pregnancies reflect an unmet need for family planning, and are part of health disparities. Using the only database to inquire about pregnancy intention among women in Switzerland, this study examined the relationship between immigrant documentation and unintended pregnancy (UP). Among pregnant women presenting to a Swiss hospital, we compared pregnancy intention between documented and undocumented women. We used logistic regression to examine whether undocumented status was associated with UP after adjusting for other significant predictors. Undocumented women had more unintended pregnancies (75.2 vs. 20.6 %, p = 0.00). Undocumented status was associated with UP after adjustment (OR 6.23, 95 % CI 1.83-21.2), as was a history of psychological problems (OR 4.09, 95 % CI 1.32-12.7). Contraception non-use was notably associated with lower odds of UP (OR 0.01, 95 % CI 0.004-0.04). Undocumented status was significantly associated with UP, even after adjusting for well-recognized risk factors. This highlights the tremendous risk of undocumented status on UP among women in Switzerland.

Background Colon cancer is one of the most frequent cancers in Europe, and the second most frequent cause of cancer death in the Netherlands [1]. In 2014, the agestandardized incidence rate of CC was 28.4 per 100,000 , comparable to that of other Western countries [2]. Diagnosis and treatment of CC are framed in a welldocumented, evidence-based set of guidelines, developed by a multidisciplinary group of specialists. The primary treatment for non-metastatic CC is surgery. After the operation, adjuvant chemotherapy should be considered for patients with lymph node metastases upon pathologic assessment of the resection specimen. Therefore, adequate lymph node evaluation is important [3]. Research in the Netherlands has shown a generally improving quality of CC care over time [4]. However, no specific attention has been paid to differences in treatment of CC across ethnic groups in the Netherlands, while several studies showed ethnic differences in health care utilization in the country [5]. Studies from the USA [6][7][8] show a lesser accessibility of screening care for ethnic minority groups [9], a lower use of adjuvant chemotherapy [10] and a lower rate of adequate lymph node evaluation [11]. These ethnic differences in accessibility and quality of care cannot be fully attributed to the generally lower socioeconomic position of ethnic minority patients. Geographical concentration of ethnic minority patients in some hospitals might contribute to differences in quality of CC care. A Dutch study showed variation across hospital types in treatment and outcome of patients with CC [12]. However, the USA situation is not fully comparable to the Dutch situation, due to fundamental differences in health system organisation, screening policies , insurance coverage and their impact on ethnic and socioeconomic differences in access to health care. Therefore, the present study investigates ethnic differences in CC care in the Netherlands, and their impact on survival. The research questions are: 1) Are there ethnic differences in guideline-recommended care for patients with colon cancer?; 2) Are ethnic differences in CC care attributable to groups differences in socioeconomic factors and hospital characteristics?; 3) Do differences in CC care affect ethnic differences in survival? --- Methods --- Theoretical framework The analyses were framed in a conceptual framework adapted from the Behavioral model of access to medical care [13] and the Equity framework [5]. According to these, use of healthcare does not only result from medical need, but is also influenced by patients' socioeconomic and cultural factors. These vary by ethnicity and may therefore explain ethnic variations in CC care. Equitable access to medical care implies that medical need is the key determinant for healthcare use, and that socioeconomic and cultural aspects influence health care use as little as possible. Therefore, ethnic origin should also ideally not influence the use of healthcare, unless it directly relates to the medical need, or influences the outcomes of care [5]. Figure 1 presents the relationships studied or accounted for in the present paper . The dashed lines represent other relationships hypothetically at play in ethnic differences in CC treatment and survival, but not investigated within this paper. --- Data and inclusion Data were extracted from the Netherlands Cancer Registry [1], a nationwide population-based registry including all newly diagnosed malignancies. Main sources of notification are the automated pathology archive and the Hospital Discharge Register . NCR data on patient characteristics, tumor characteristics and treatment are collected from hospital patient files by specially trained registration clerks and coded according to a national manual. Topography and morphology are coded according to the International Classification of Diseases for Oncology and stage according to the TNM classification [14,15]. Data quality is high and completeness is estimated to be at least 95% [16,17]. For this study, data on all CC patients diagnosed between 1996 and 2011 were probabilistically linked to three databases of Statistics Netherlands at individual level: the Dutch population register, the causes of death register and the social statistics database. Of all records in the NCR, 98.2% were successfully matched to the CBS databases. Information on the quality and completeness of the databases of Statistics Netherlands can be found elsewhere [18]. --- Explanatory variables and confounders Ethnic origin, age, gender Ethnic origin was obtained from the CBS population register. Categories were Dutch, other Western, Turkish, Moroccan, Surinamese, Antillean and other non-Western, using the definition established by CBS [19]. Age at diagnosis and gender were obtained from the NCR. --- Socioeconomic status We used type of employment/main income source as SES indicator. Data was obtained from the CBS social statistics database and categorized into 8 modalities: employed, self-employed, managing director, other active, unemployed , sickness leave, retired, and all others persons without income. --- Medical need Medical need was approximated by tumor site , transverse , left-sided and overlapping lesions or not otherwise specified ) and stage at diagnosis. All data were obtained from the NCR. --- Hospital characteristics Professional expertise was approximated using NCR data on hospital type and hospital volume . Information on the region of hospital was also used in the analyses, to adjust for regional differences in concentration of ethnic minorities. --- Outcome variables We used adequate lymph node evaluation, adjuvant chemotherapy and anastomotic leakage as CC care quality indicators. The choice for these indicators was based on current guidelines [3] and on the availability of data. All indicators were retrieved from the NCR. Survival was operationalized as 5-years mortality . Since accuracy of cause of death is limited for colon and rectal cancer separately [20,21], we used colorectal cancerspecific mortality. Colorectal cancer specific mortality was retrieved from the Cause of Death Register . --- Statistical analyses Treatment Multivariate logistic regression analyses were performed to examine the association between ethnicity and adequate LN evaluation, defined as 10 or more evaluated LNs, among patients with stage I-III disease diagnosed in the period 1999-2011 and who underwent surgery. Variables on 1) age, gender, medical need, 2) hospital characteristics and 3) SES were entered stepwise into the model, to explore the influence of these factors on ethnic differences in adequate LN evaluation. Similar analyses were performed to analyse the association between ethnicity and adjuvant chemotherapy among patients with stage III disease in 1996-2011 who underwent surgery. Likewise, the association between ethnicity and risk of anastomotic leakage among patients who underwent surgery was examined stepwise. --- Survival We used Cox proportional hazard models to investigate the influence of ethnic differences in adjuvant chemotherapy on survival. These models were built stepwise, introducing in the last step the receipt of adjuvant chemotherapy, to examine the impact of ethnic differences in the receipt of adjuvant chemotherapy on survival. Follow-up time was calculated as the time from the CC diagnosis to the end of follow-up or death . All multivariate analyses were adjusted for the year of diagnosis. Data were analysed using SPSS, version 13.0. --- Results Table 1 displays patients' characteristics: Dutch patients accounted for 89.6%, other Western patients for 8.5% and non-western patients for 1.9% of the study population. The ethnic differences in gender, type of main occupation/income, age and stage at diagnosis were statistically significant . --- Treatment 'Other Western' and all groups of non-Western stage I-III patients were more likely to receive adequate LN evaluation than Dutch patients. These differences were statistically significant for the 'other Western' , the Turkish, the Moroccan and the Surinamese groups . After adjusting for age, gender and medical need, the proportion of patients who received adequate LN evaluation was statistically significantly higher only for the 'other Western' group than for the Dutch reference group . Adjusting analyses for SES and/ or hospital characteristics did not further explain the observed ethnic differences in adequate LN evaluation . In the univariate analyses , stage III patients of all other ethnic origins, except the Moroccan group, were significantly more likely to receive adjuvant chemotherapy than the . Multivariate models showed that patients of Moroccan and Surinamese origin were significantly less likely than Dutch patients to receive adjuvant chemotherapy. Adding and exchanging SES and hospital characteristics had little effect on the observed results. 'Other Western' and 'other non-Western' patients were significantly more likely than Dutch patients to experience anastomotic leakage after surgery . In all other models, only the 'other Western' group was significantly more at risk for anastomotic leakage than the Dutch. Adding hospital characteristics, as in Model D, seemed to have an explanatory effect similar to the one of SES on reducing ethnic differences in point estimates. to the analyses to examine the impact of differences in adjuvant chemotherapy on differences in survival between groups, did not change this. However, the HRs of the Moroccan group showed a noticeable decrease when adding information on adjuvant chemotherapy. All-cause mortality rates was significantly higher among Moroccan and 'other non-Western' origin stage III patients who underwent surgery than among the Dutch, after adjustment for age, sex and medical need . Addition of the variable 'adjuvant chemotherapy' to the analyses , to examine the impact of differences in adjuvant chemotherapy to differences in survival, the HRs of the Moroccan group dropped under significance level, while the higher HRs of the 'other non-Western group' remained unchanged . --- Discussion This nationwide study showed ethnic differences for three indicators of CC care, which could not be fully explained by differences in socioeconomic and hospital-related characteristics. Adequate LN evaluation was more likely to take place for patients from other Western countries, compared to the Dutch. However, this same group had also a slightly higher risk of anastomotic leakage after surgical resection. Adjuvant chemotherapy was less likely to be administered to Moroccan than to the Dutch, and this was not fully explained by differences in socioeconomic factors and hospital characteristics. Survival analyses did not show a significant effect of the observed ethnic differences in receipt of adjuvant chemotherapy on CRC-specific mortality. However, the lower receipt of adjuvant chemotherapy in the Moroccan group was significantly associated with a higher all-cause mortality rate. This outcome was not found in the 5-year colorectal cancer mortality analyses. This could point at another explanation: in the all-cause survival analyses, adjuvant chemotherapy might be a marker for comorbidity, and therefore explain the excess all-cause mortality of the Moroccan group. Information on comorbidity was not available in our study, but the Moroccan group is known to suffer more often from chronic diseases like diabetes [22] and hypertension [23]. Noticeably, CRC patients with diabetes have been shown to receive less often chemotherapy than non-diabetes patients [24]. Therefore, the effect of adjuvant chemotherapy on the excess mortality rate of the Moroccan CC patients in our study might be standing for a higher comorbidity within this group, which would explain the higher 5-year all-cause mortality, without having any significant effect on the 5year colorectal cancer-specific mortality. The lack of comorbidity data in the NCR limited the interpretation of the present analyses. Also, information on the presence and treatment of metachronous metastases was not available for this study, while this factor also influences all-cause survival. Other indicators of need for CC care were however taken into account, like stage, tumour localisation and differentiation. Other factors suggested in the literature to be at play in ethnic differences in CC care include differences in insurance coverage [5,6] and difficulties in patientprovider interaction. Different insurance coverage does not form a likely explanation in universal access healthcare systems as in most European countries. However, a language barrier, lower patient health literacy or cultural differences may complicate the patient-provider interaction, and challenge the quality of care provided. A decision about adjuvant chemotherapy requires patient involvement, and the above-mentioned difficulties might explain the lower receipt of adjuvant chemotherapy for the Moroccan group. The similarity in LN evaluation and anastomotic leakage between the Dutch and all non-Western groups involved is also in accordance with this thought, these quality indicators being less related to the patient active involvement in the decision-making process. However, the increased likelihood of LN evaluation and anastomotic leakage among 'other Western' patients remains unexplained. Morphological or anatomic differences between 'other Western' patients and the Dutch patients might explain parts of the observed differences. The relatively low numbers in the non-Western ethnic minority groups limited the statistical power of the analyses for the present study. The numbers are in accordance with expectations, given the low incidence of colon cancer in these relatively young groups. Nevertheless, this study included all CC patients diagnosed in the Netherlands over a period of 15 years. Linking NCR data to the Dutch population register made the ethnic categorization possible, and linkage with the causes of death register and the social statistics database enabled further analyses and model adjustments. Future research should primarily focus on the role of comorbidity. Registries offer an outstanding opportunity to investigate groups differences in guideline-recommended care. However, the lack of information on comorbidity within the NCR limits the scope of conclusions, and should therefore be tackled. International research showed the importance of this information when studying ethnic differences in CC survival [25]. The role of communication and health literacy also deserves attention when looking at ethnic differences in treatment for CC. The interaction between physician and patients should be investigated specifically, and research should deepen the motivations of physicians when deciding upon treatment in an ethnically-diverse patient population. Qualitative techniques might be a very appropriate choice when unravelling the mechanisms at play in this interaction. --- Conclusion In conclusion, ethnicity should be taken into account when assessing quality of CC care in the Netherlands and elsewhere. Important differences are present, which cannot be solely attributed to tumor stage, age and gender differences, or differences between hospitals, and therefore point at ethnic inequities in quality of CC care. This is all the more important as ethnic inequalities in guideline-recommended care might also lead to ethnic inequalities in mortality, as shown in this study's results. --- --- Competing interests The authors declare that they have no competing interests. --- --- ---

Background: Ethnic differences in colon cancer (CC) care were shown in the United States, but results are not directly applicable to European countries due to fundamental healthcare system differences. This is the first study addressing ethnic differences in treatment and survival for CC in the Netherlands. Methods: Data of 101,882 patients diagnosed with CC in 1996-2011 were selected from the Netherlands Cancer Registry and linked to databases from Statistics Netherlands. Ethnic differences in lymph node (LN) evaluation, anastomotic leakage and adjuvant chemotherapy were analysed using stepwise logistic regression models. Stepwise Cox regression was used to examine the influence of ethnic differences in adjuvant chemotherapy on 5-year all-cause and colorectal cancer-specific survival. Results: Adequate LN evaluation was significantly more likely for patients from 'other Western' countries than for the Dutch (OR 1.09; 95% CI 1.01-1.16). 'Other Western' patients had a significantly higher risk of anastomotic leakage after resection (OR 1.24; 95% CI 1.05-1.47). Patients of Moroccan origin were significantly less likely to receive adjuvant chemotherapy (OR 0.27; 95% CI 0.13-0.59). Ethnic differences were not fully explained by differences in socioeconomic and hospital-related characteristics. The higher 5-year all-cause mortality of Moroccan patients (HR 1.64; 95% CI 1.03-2.61) was statistically explained by differences in adjuvant chemotherapy receipt. Conclusion: These results suggest the presence of ethnic inequalities in CC care in the Netherlands. We recommend further analysis of the role of comorbidity, communication in patient-provider interaction and patients' health literacy when looking at ethnic differences in treatment for CC.

Introduction Loneliness is an increasing societal issue world-wide [1,2] with severe negative effects on health and wellbeing [3]. An aging population often leads to greater loneliness, which negatively affects public health and quality of life. Loneliness is the tension between a current and a desired situation of social interaction and connectedness [4]. I will attempt the study of resilience or 'flexibility' of older adults to counter loneliness while they are supported by humanoid robots. To this end, a novel theoretical framework of resilience is proposed, which is open to formal modeling and empirical testing. Note, however, that the longitudinal study proposed in the current paper will take a number of years before completion. Therefore, I want to confront the theoretical framework and envisioned method with the readership before putting great effort into sampling longitudinal data for the wrong theoretical reasons or with a flawed method in place. In other words, the current paper develops hypotheses and proposes how to measure these but does not present actual data, which is work left for the future. Thus far, interventions that directly address loneliness do not seem to be too successful [5]. This might be because such approaches wish to diminish the negative instead of improve the positive . It would be worthwhile if people could counter loneliness themselves by enhancing their resilience, which to date is left untried [6]. I would want to characterize personal resilience as the flexibility of an individual to positively deal with hardship. Because resilience is used as somewhat of a container term, the definitions of resilience are rather tentative and the level of data aggregation could sometimes benefit from more determination. Although the notion of resilience seems to be commonly understood, an explanatory model is still wanting and mathematical modeling is practically absent. Yet, I consider a mathematical account with explanatory power as an important requirement on a robust and predictive theory, which would be the overall scientific aim. In knowing the state of the art, however, formalization, robustness, and predictive value will be more of an ideal than a feasible result of this paper, so I want to do some groundwork instead and prepare for that later effort. For now, my objective is to arrive at more explicit definitions and demarcations, which allow the formulation of an explanatory model that eventually can be tested empirically and implemented in applications of human-humanoid robot interaction . One of the first things to realize is that resilience is always related to something else. In this case, I wish to study resilience in older adults, who increasingly face the hardship of loneliness [7]. Resilience in combination with loneliness has not been studied before and the main question is how they affect each other: will more resilience mitigate loneliness or will increased loneliness decrease resilience? Older adults respond well to robots, particularly when they feel lonely [8]. However, Frennert and Östlund [9] express their concerns that a humanoid robot's social role in the lives of older adults often remains implicit, that methods for longitudinal study are wanting, that seniors and robot developers are mutually uninterested in the development of social robots for older adults, and that conceptual clarity in HHRI is missing for matters that concern older adults. Additionally, Frennert and Östlund [9] state that in HHRI often technical determinism takes precedence over the social construction of humanoid robots. In the current paper, I attempt to tackle these issues by exploring how resilience and loneliness are affected by social connectedness and relationship [10][11][12]. Meanwhile, I pose the question whether robots can make up for a degraded social environment, improve resilience in older adults, and in so doing mitigate their loneliness? Figure 1 provides a general overview of my argument. It may serve as a guideline for the reader and I will refer to it throughout the paper. It assembles all the research questions in relationship to each other. It provides for the conceptualization of resilience as a capacity, a process, and an outcome. It then discusses robot support of the resilience process to ease loneliness as flanked by longitudinal studies into resilience , using a particular robotmediated conference-call system. In the remainder of this paper, I attempt an explanation of the way social robots may positively affect the relation between resilience development and loneliness reduction. I start from the assumption that people are able to recover from loneliness themselves and that the robot merely is a facilitator or instigator of that process. In reducing loneliness indirectly, the progression of resilience complements methods that directly reduce loneliness. From the existing literature, I will argue that, conceptually, resilience is a combination of a capacity, a process, and an outcome. I will pose six research questions in relation to a new theoretical framework that helps address those questions. In the end, I also propose a method to test that framework longitudinally with older adults. Note, however, that the test results of the proposed method are pending still. The present paper merely provides a conceptual framework of HHRI and several interaction schemes, addressing the relationship between resilience development and loneliness reduction through humanoid robots. --- Resilience The overall scientific objective, as stated, is to create a robust and predictive theory of personal resilience. And to get there, the first question would be . Sometimes it is an outcome or a process, and sometimes it is a personal trait. In psychosocial intervention, resilience as a process pertains to positive adaptation to misfortune to achieve certain goals [17,18]. Goals may be physical or spiritual but do not always have to be achieved completely [19]. Positive adaptation depends on personal traits, moderated by the environment [20,21]. As an outcome, someone feels more or less resilient [19]. People may show different levels of resilience dependent on age, the stage of life, or the domain [18]. Resilient individuals together form a resilient organization, society, or culture [22]. The apparent conceptual ambiguity about resilience being an outcome, process, or trait may be resolved if we see them as different aspects of the same system . Regarding personality, resilience is the capacity to overcome a crisis situation in a positive way. That capacity may be inborn but also can be learned [23] through a whole range of techniques such as "mindful meditation" and "psychosocial" intervention [24], by giving meaning to suffering and constructing the meaning of life, sense-making, or storytelling [19]. Applying such techniques to achieve higher levels of resilience may be called the resilience process. As an outcome, the level of resilience may fluctuate given certain circumstances. Hence, I will speak of resilience capacity, resilience process, and level of resilience as three related but different theoretical dimensions . The literature seems to forward two personal and one environmental factor that affect resilience. One personal factor is the ability to successfully interact with the environment to realize one's potential and to achieve one's goals [25]. That could count as an aspect of resilience capacity, the ability to interact. The other personal factor the literature mentions pertains to what can be called self-regulation skills [26] such as coping potential and reappraising the meaning of a bad situation [27] . This also may count as resilience capacity, having the skills to regulate oneself and the potential to deal with a bad situation. Thus, resilience capacity would at least comprise interaction seeking and self-regulation skills, particularly coping potential . Following from the two factors that make up resilience capacity, the resilience process would be to actually engage in interaction with the environment and to indeed deal with hardship that is encountered. Particularly the ability of problem-focused coping seems to increase the level of resilience [11], whereas emotionfocused coping and neuroticism cause adverse effects [11]. It turned out that, with emotionfocused coping, people perhaps expected less from life but this realization in itself made them feel lonelier [5]. The outcome of the resilience process probably coincides with the environmental factor the literature mentions as being conducive to high levels of resilience: to keep close relationships with others [26]. Not having them is a crisis in itself. Close relationships offer emotional security [26] and instill hope [19]. They provide knowledge about what helps, what to avoid [26], and where to find resources [28]. A high level of resilience in itself moderates the negative effects that, for example, social neglect has on psychopathology such as depression and, indeed, loneliness [11]. --- Loneliness Unlike personal resilience, studies on loneliness are bountiful. Loneliness diminishes physiological strength and increases health risks such as depression [3], dementia, and cardiovascular diseases. Loneliness predicts excess mortality [12], particularly in combination with depression [2]. Half the people of 80+ experience loneliness [7]. The degradation of one's social environment, grieve, fewer visits from friends, and deteriorating health aggravate this chain of events [29]. Several factors seem to cause or intensify loneliness . Being socially embedded is evolutionary most essential and social relationships should have at least a minimum level of quality [10]. When such criteria remain unsatisfied, loneliness emerges [10]. In self-determination theory [30], autonomy, competence, and relatedness are basic needs that motivate people to act. Satisfaction of these needs predicts personal wellbeing. Feeling lonely may be closely related to personality or may be a temporary circumstance [4] . Not everyone has the same need for relationship. Introverts, for instance, may have fewer and less intense social connections but may not feel lonely. They connect in a less personal manner than extraverts do [4,31] . Gender also may be of influence. Women on average live longer than men [32] such as wanting to care [33] , although admittedly the feminine role of women is declining since the baby boom [34]. People with more feminine qualities but who lack social contacts probably feel all the more lonely. More masculine, assertive, achievement and successoriented people may feel less so. All in all, loneliness has little to do with the number of people in one's environment [7] but rather with the quality of the contact [10]. In the absence of high-quality interaction, one may feel lonely while many come to visit. This gives rise to the second research question : can the influence of factors that increase the level of loneliness of older adults be pushed back by making people more resilient? Certain personalities seem to be more or less vulnerable to feelings of loneliness . Loneliness increases with age and may be more severely felt when someone's orientation is towards the feminine. Social connectedness may ease the loneliness, provided that the quality of the contact is sufficiently high [10]. However, the literature also reports possible countereffects. It might be that in the face of adversity the level of feeling resilient is drained, indeed, by feeling lonely [3,5]. Put differently, increased levels of resilience may lessen feelings of loneliness. Or will high levels of loneliness be detrimental to feeling resilient? Or do both happen at the same time as a kind of self-enforcing vortex? The third research question, then, is how are levels of resilience and loneliness interrelated in terms of mediation, moderation, or direct effects? Are we dealing with an upward or downward spiral and, if so, how to interfere with its direction? This brings us to the application side. To observe resilience in terms of successful interaction, self-regulation skills, and close relationships, or to study the way loneliness and resilience are intertwined, we need a test case. Many older adults have fewer and less profound interactions, skills, and relations. There may be a way out, however, if we can enhance their resilience to such standards that feelings of being lonely at long last are reduced. And so a fourth research question emerges : can a general model of personal resilience be retrieved in an area such as loneliness in older adults? In what way does the application domain affect the model's structure? --- Robots Counter Loneliness In this section, I cite a number of studies that report effects of loneliness reduction in older adults, using social robots. In their literature review, Broekens, Heerink, and Rosendal [35] find that research methods are still immature and confounding variables lead to mixed results. However, these authors also state that quite a number of studies report less loneliness in older adults with a companion robot as assessed with loneliness measurement scales. For roughly 15 years now, beneficial effects are reported using pet-like companion robots to counter depression and/or loneliness. Early longitudinal research by Wada et al. [36] found reduction of depression in older adults while using the PARO seal robot. Banks, Willoughby, and Banks [37] compared companionship of a real dog with that of the AIBO robot dog and did not find differences between the two: In both cases, loneliness was reduced as compare to a control group that had nothing. Bennett et al. also reported beneficial effects with respect to loneliness in older adults while employing the PARO machine [38]. Randomized controlled clinical trials with older adults showed that the company of a resident dog or the PARO robot reduced loneliness as compared to a control group who had neither [39]. Randomized controlled clinical trials in Hong Kong obtained better mood, more social interaction, and more communication in older adults with dementia after interaction with the PARO pet robot [40]. It seems, then, that robots can do what listening radio and watching TV cannot: robots can intervene with the older user in an interactive manner. In that respect, Dautenhahn, Campbell, and Syrdal [41] point out that it may not be the direct interaction alone that is helpful to reduce loneliness. It also may be the mediating role a robot fulfills, bringing people together and easing loneliness that way. Robots apparently can counter loneliness through direct contact or by bringing people together. That from an applied viewpoint is good news. In view of the development of resilience theory, however, do robots counter loneliness directly or do they do so by enhancing resilience first, which in turn reduces loneliness? This would be my research question RQ5 . Or in view of RQ3 , does the reduction of loneliness actually increase resiliency, not the other way round? In looking back at what we found so far robots may ease someone's loneliness but there are no studies stating that robots boost resilience, simply because that question was not asked before. Literature stated that a focus on problemfocused coping seems most beneficial to increase the level of resilience [11]. Thus, we should have a robot that offers its user the strategies to cope with setbacks in a problem-focused way . In other words, we need to develop a protocol for the robot to coach its user to resilience. That protocol, Pathways to Resilience or PAR is discussed in the next section. However, the robots in the loneliness studies cited in this section did not have an intervention protocol or did not perform any deliberate actions to counter loneliness. They were just there. In other words, the robot's physical presence may ease feelings of loneliness without a resilience intervention needing to take place. This would count as a possible confounding part of any resilience intervention by a robot . Yet, with that protocol in place, we can test the magnitude of the effect of direct intervention on the level of resilience . Without the protocol, we can control the mere physical presence of the robot and to what extent a robot intervention with coping strategies installed has added value. --- Pathways to Resilience If the robot is to interfere with the habits of a lonely person, it should have coping strategies ready when the user so requires. Therefore, we need a robot that is capable of stimulating problem-focused coping [11]. For a robot to execute such behaviors, it should run a so-called coping protocol by which it encourages resilience and through that eases loneliness. Next, I will explore the first steps towards such protocol. The robot may use that to coach the user in dealing positively with life's challenges. This protocol is called Pathways to Resilience . PAR describes the process of resilience. To build a formal model of coping strategies, I start from Parsons et al. [42], who formulated an adaptive process of resilience as people deal with stress and adversity. Their 'mapping system' relates current situations to perceived needs and goals and checks what information is needed for response. If the desired result is not met, other means are selected to get a more adaptive outcome, taking earlier experiences into account. Executive strategies can be altered based on experience to adapt to an adverse situation. Figure 2 illustrates that there is not just one road to resilience. It compiles a number of pathways, including strategies to help a person face life's setbacks. It might just be that these strategies when applied properly may constitute the high-quality social interaction that make people feel connected [7] . First, Figure 2 assumes that resilience may be a perception of one's individual approach to a situation; it may also be the collective perception of a group. Second, that perception may be internal or it may be external . Those perspectives may differ. Someone may think s/he is fine although the doctor has diagnosed a serious illness. The first thing a social robot should ask with respect to resilience is whether people experience a setback at all. Adverse situations could be the transition to a care institute. They could be environmental barriers, unsafe neighborhoods, migration patterns, inaccessible housing, and inadequate resources for socializing, which are all mentioned in response to feeling lonely [16]. People may be insecurely attached [43] or may be depressed, feeling lonely [44]. However, if people do not experience this as a crisis situation ), they are 'resilient' for the purpose of this model because in their view nothing is the matter, although an external observer may judge otherwise. If someone does experience a setback ), the question is what s/he will do to deal with the hardship. As coping strategy, the robot checks on supportive others , exceptional events , shaping possibilities , and self-esteem . Users consciously think about these matters, shifting focus from problems to abilities, a reframing and reappraisal technique in family practice [27] . Your daughter is not nosy, she is caring [27]. Deficits are relabeled as strengths, providing a new meaning to a bad situation, opening possibilities to shape a new context. What someone prefers may be a matter of psychology, economic pressure, acculturation, or religion but the bottomline is the question whether it helped. Did employment of the strategy improve the situation? If so, that person finds him/herself 'resilient, ' although again, someone else may think differently. The loop continues because, in the new situation, new setbacks may happen that need to be dealt with. If the person feels s/he did not improve , there will be no or less resilience felt. After all, all effort was for nothing. The question the social robot then poses is whether one would want to try another strategy if the previous one did not work. For some people this is impossible. They know but one way to respond and merely increase the effort in trying the same approach time and again . However, the situation may change through external factors so that in spite of repeating the same behavior the hardship passes by anyway . If applying a new strategy to the old situation does work and the setback is overcome , the level of resilience rises. If not, the assessment of the adverse situation starts all over again, making a choice from the strategies the robot offers to change the situation. An example to follow for implementation of PAR is the FearNot! system for virtual storytelling that helps schoolchildren deal with schoolyard bullies [45]. In an adaptation of the FearNot! system, the robot will be capable of appraising the relevance of an occurrence, can independently choose an action, and ask the user what his/her related emotions are. If an event happens , the robot may query the user for goals that are achievable within the new situation [38]. In view of the new goal, the robot selects an action. For instance, it approaches the user with a compliment or avoids a sensitive topic. It may also start a coping strategy . It also may attempt emotion regulation of the user, suggesting a reappraisal of the importance of the original goal so to moderate the user's stress levels . Next goes an example of a check by the robot after the coping intervention ), which I modeled after [46] ( Automation of the coping protocol is convenient to systematically test effects of coping on resilience, which demands exact replication of the treatment for each participant. Exact replication is something a human confederate cannot deliver but a robot can. Additionally, the physical presence of the machine, its interaction possibilities, and human-like performance make a robot more suited as device to induce the treatment than, for instance, radio, TV, or Facebook. On the applied side, the repeatedly stated shortage of hands [1] in eldercare requires that a robot can support people independently [8,47], for which some form of automation is indispensable. --- Need Satisfaction through Robots Quite unexpectedly, the introduction of a social robot into resilience and loneliness studies also introduces a contamination problem. As mentioned in the section on loneliness and illustrated by Figure 1, loneliness transpires from the unfulfilled need for relationship with another human being [30,48]. However, studies show that robots already ease loneliness through their physical presence [47,49]. Thus, the need for relationship can be compensated by a nonhuman, synthetic other [50]. Scientifically, it is germane to find out how much added value the robot's stimulation of coping behavior provides above and beyond the robot's physical presence. This introduces the sixth research question : how does a robot make up for the need for human relationship and can we measure it? Measures of need for relationship refer to humans, not to robots. To answer RQ6, measures of need for relationship should be adapted to whether 'the robot fulfills that need' . This also opens the possibility to study whether a robot can make up for a degraded social network. In view of RQ6, it would be wise to construct a new set of questionnaire items based on the need for human relationship [48] but combined with measures to evaluate the social presence and appeal of synthetic characters [49]. The new scale that measures need satisfaction through robots is called NeStoR. The 'need' part of NeStoR is based on self-determination theory: people have a basic need for relatedness; feeling accepted by and important to others, to feel cared for, and to care for them [48] . In line with RQ6, indicative items will address being cared for, being acknowledged, and feeling a sense of belonging; counterindicative items should address feeling isolated, misunderstood, instrumentally used, and unconnected. To measure NeStoR, an adaptation could be made of the Relatedness scale from the Basic-Need-Satisfaction- questionnaire [30]. For example, "I really like the people I interact with" and "I consider the people I regularly interact with to be my friends" become "I really like the robot I interacted with" and "I consider the robot to be my friend," respectively. These human-oriented items are then connected to social presence of synthetic characters, the experience of "being with another" [49], as if someone else is there although not in person. This is the 'robot' part of NeStoR. The companion may not even be a person as long as some social actor is physically present in the room and responds in a human-like manner. This enhances the effect of having real company and that a positive interpersonal and emotional connection between communicators is established [51]. NeStoR, then, makes use of this sense of coexistence, of human realism, probing the degree of awareness of the artificiality of the social interaction with the robot, or as counterindication, the unawareness of the social mediation [52]. For example, "I felt like I was in the presence of another person in the virtual environment" [52] becomes "With the robot, I felt like I was in the presence of another person." It may be that the need NeStoR assesses is different for different people. Perhaps feminine and introverted people are satisfied by robot company but masculine and extraverted people are not. In other words, we can cross-tabulate the factors that cause of aggravate loneliness and arrive at the predictions for NeStoR in Figure 3. The plot shows the expectation that personality , gender role , social connectedness , and age have a relationship with NeStoR. Figure 3 indicates to what extent a surrogate can make up for the wish to have real people around that offer the right form of social connectedness. In Figure 3, NeStoR increases when people are more introverted and are more feminine and when the quality of their social connections is degraded, which happens when they grow older. In Figure 3, the linear-relation hypothesis is summative in that each factor adds to NeStoR in equal measures. The hypothesis on curvilinearity assumes synergistic interactions, where the combination of factors is stronger than the sum of their effects. Linearity is the simplest assumption; curvilinearity may be more realistic [53]. --- Journal of Robotics --- Resilience Double Mediation Moderation Model The overall objective of the current paper was to establish a new theory of personal resilience integrated with the factors that affect loneliness. That theory should inform humanhumanoid robot interaction to explain loneliness reduction and the build-up of resilience in older adults through social robots. To answer RQ1-6 , I formulated a new model of personal resilience: ReDeeM . With ReDeeM , I try to do justice to the insights and findings from the research literature regarding personal resilience while combining that body of knowledge with the one on loneliness. Whereas PAR described the process of resilience, ReDeeM describes the level of resilience as an outcome and a moderator of other factors. It includes the PAR protocol by means of robot intervention. Next I formulate a number of hypotheses that are represented by relations in ReDeeM . Backbone of ReDeeM is the empirically established relation between personality and resilience , particularly the ability of problem-focused coping [11]. By contrast, emotionfocused coping and neuroticism were found to have an adverse effect on resilience [11]. Personality also has another effect : literature states that more extraverted people have stronger needs for relationship than introverts [4] . When such need is unfulfilled, loneliness increases . The route from H2 to H3 in Figure 4 shows the first mediation: the factor need satisfaction through robots brokers the relationship between personality and loneliness. However, literature shows that high levels of resilience moderate the negative impact of emotional neglect on psychiatric symptoms such as depression [11]. Likewise, resilience may moderate the relation between need satisfaction and loneliness . Yet, I also suspect that loneliness may backfire , causing resilience to drop . I dubbed this constellation the Loneliness-Resilience Spiral or LoneRS assumption , describing an upward or downward spiral that reinforces itself. If so, then the LoneRS assumption represents the second mediation in the model with loneliness in between need satisfaction and resilience. Social factors such as gender role may increase the need . How well do people fit into the traditional gender stereotypes ? Additionally, the quality of social connectedness satisfies need satisfaction and may be a direct cause of not feeling lonely any more . Care should be taken to focus on the quality of relationship rather than the frequency of contact or the number of people surrounding the older adults. With age, social connectedness declines for which an intervention through social robots may compensate . There are two sides to the robot intervention. Literature shows that its physical presence provides a sense of companionship [47,49]. Second is the behavioral change the robot will attempt, offering strategies that encourage problemfocused coping in older adults , which supposedly was the prime source of improving resilience [11]. In sum, I offer the hypotheses of ReDeeM, where indicates a positive correlation and a negative correlation: Personality enhances resilience The more extraverted, the higher the need The more the need is satisfied, the less lonely one feels Resilience moderates the adverse effects of unfulfilled need on loneliness Reduction of loneliness leads to increased resilience The more femininity, the higher the need The less connected one feels, the greater the need The less connected one feels, the lonelier one feels With age, social connectedness deteriorates Physical presence of the robot enhances connectedness Robot's coping strategies enhance user's problemfocused coping The combined effect of social-individual factors on need satisfaction is either linear or curvilinear --- Materials and Methods In this section, I offer a method to test the effectiveness of robot intervention in a longitudinal setting . Readers should be aware, however, that no actual data will be presented because longitudinal studies take years of sampling. This section is more of a discussion piece of how to approach issues of methodology before doing the actual work. With hypotheses derived from the novel theoretical framework of resilience, the method should follow a switching-replications design in which video footage of older adults in interaction with robots are rated by 'blind' observers for resilience, loneliness, etc. at three moments in time. --- Participants. Pew Research Center investigated over 7000 US seniors for communication technology use and found a diverse picture [54]. Currently, roughly 25-50% of the seniors of 70+ own a cellphone and smartphone, are on the Internet, or use broadband services. About 33% own a tablet or computer and are active on social media. Yet, a larger number have a distant relationship with technology, more so the older, less educated, and financially vulnerable they are. Older adults report not to be skillful; they face physical barriers and rely on others to set up technology and show its usage. However, those who use communication technology state that it enriches their life and positively impacts society [54]. Given this positive attitude but negative aptitude, technology that supports older adults should be telephony based, the best known option to this group. Computers and tablets may be functionally appropriate to look up information or to chat [55]; however, operating the interface may be a barrier. One should be able to talk to it, not type, swipe, scroll, click, or browse it. Moreover, the machine should explain itself, literally. With age, friends and family become fewer and the barrier to contact a stranger becomes higher. Therefore, the machine should make connections independently, leaving the decision to engage with the older adult. Therefore, I propose to let a robot make the call, facilitating social connectedness, looking up information, and providing active support through PAR. With the phone on the hook, the machine has physical humanoid presence, serving as a social surrogate when no one is around. Because females are the larger group and most have played a feminine role during their lifetime, I focus on 80+ females with an introverted personality, an impoverished social network, and a diagnosis of pathological loneliness. Because introverts connect in a less intimate way [4] and tend to connect more indirectly through technology [31], robot companionship may work well for them. --- Design. With respect to experimental design, I want to discuss the combination of qualitative and quantitative data and their respective means of sampling. Older adults find laboratory experiments and filling out questionnaires rather challenging [56,57]. However, observational casestudies render data of low reliability and generalizability [58]. Therefore, I propose a mixed method in which qualitative observations are quantized by 'blind' observers in an experimental setting. As Happ puts it: ". . .there is little standardization of mixed methods research practices and relatively little guidance for data combination or integration. This is an area that provides opportunities for methodological creativity. . ." [56]. In mixing qualitative and quantitative methods, four levels are discerned [58]: separate data collection and analysis, results of one method inform the other, comparison of separate results, and merging data sets through data transformation followed by additional analyses. Regarding 2, ample examples exist that in geriatric studies quantitative data are used in a qualitative follow-up to evaluate the ecological validity of the numerical results [56]. I do things the other way around by "quantizing" the qualitative data. In Hoorn [59], I proposed videotaping older adults in interaction with the robot in a switching-replications design. Next, I elaborate upon the idea so that some parts show some overlap with [59]. I propose using the video recordings as a stimulus set in a structured-questionnaire study in which a large sample of 'blind, ' not family-biased, observers assess the behaviors of the interactants. The results are open to robust statistical techniques . This is different from common approaches where three raters categorize observations according to a protocol , which is too dependent on interview style and grouping of concepts [58]. My approach leaves older adults in their homes and yet renders reliable measurements , allowing for full model fit as well as the analysis of longitudinal effects. It is literally so that ". . . no longitudinal studies found to date have tracked changes in resilience over time among older adults" [60] but my approach may make this happen. Happ has a point when she observes that it is difficult to quantize qualitative results when probabilities of occurrence of a phenomenon are unequally distributed over the sample [56]. Therefore, we should not rely on just one session with one older adult but make a large stimulus set of comparable replications that moreover is judged by more than the standard three raters, making the set-up a field experiment with laboratory characteristics with all the possibilities to evaluate the reliability of the measurements: "The next generation of mixed methods research in gerontology is challenged to combine approaches in ways that lead to responsible data integration " [56] and that is what I propose. Senior Group1 , without robots, is the control group and Group2 the treatment group, interacting with a particular robot arrangement . Group2 will be split in two . They are divided over a switching-replications design. This is a beforeafter repeated-measures design with and without robot intervention . The most important dependent measures are resilience and loneliness at time point t1-3 but all ReDeeM variables can be measured and analyzed this way: Because Group1 does not see any problems, predictions for the outcome variables are absent except that perhaps the level of resilience remains about the same at all time points . The difference with Group2a and 2b is not so much a hypothesis as it is a research question. However, the data sampled in Group1 certainly can be used to evaluate the relations predicted by ReDeeM . With Group2a, the long-term effects are tested of robot intervention . With Group2b, we test whether having no robot companionship at t1 and t2 worsens loneliness and resilience and whether that improves after receiving a robot at t3. Whether differences between Groups are significant is inconsequential. It may be that robot intervention in total renders the same effects in Group 2a and 2b. However, the statistical interaction between Groups and Times of measuring resilience is critical. Hoorn [59] predicted the following systematic: a lift-off-level-out effect would sustain hypothesis H11 that in Group2a robots inspire resilience in older adults. The effect of t2≈t3 would indicate that after initial increase by robot treatment, people in Group2a found a way to maintain higher levels of resilience independently. A lift-off-boost-up effect also would corroborate H11, observing a steady increase in resilience at t1<t2<t3. The second increase effect between t2 and t3 would point out that, in Group2a, the robot inspired and taught the skills to accelerate people's own resilience without the robot necessarily being present afterwards. This would be the most beneficial effect of the robot intervention. H11 is supported as well, if t1≈t2<t3, an incubate-accelerate effect. This is the least beneficial effect because robot support may be continuously needed although that is a worthwhile finding still. All other outcomes may be considered a refutation of H11 [59]. --- Apparatus/Materials. As said, 'loneliness can have maladaptive effects on behavior' [7] . When older adults notice that social networking, video calls, and smartphones reduce loneliness, they appreciate new technologies [15]. Probably, this will be even stronger when functions are articulated by a physical presence, with eyes and voice [61,62]. Digital communication in home care is for contact, work meetings, and arranging care [63]. Social robots could help start the contact network, which later may evolve into a meeting or arrangement network. Shy users may not likely pick up the phone and make a call. Therefore, I am working on a conference-call system with four robots, conversing with each other over the phone while four older users overhear the conversation, anonymously at first, but they can identify themselves at any moment. The conversation takes place in speakerphone mode. Call-me-Robby! shifts the burden of feeling as a burden from the user to the robot, making the user's problem the robot's. The robot wants to make a call to a fellow robot and the users listen in while the robots discuss user problems as if they were their own. Users are free to break in any time and add to the conversation, also with perfect strangers that, as a conversation piece, have a robot linked in the network as well. Note that seniors can stay at home if they want: the contact is telephonic, not necessarily in person. Because the target group is used to conventional telephones, Call-me-Robby! will be composed of a set of IP phones , which look just like regular phones, except that IP phones use an Ethernet connector to a SIP Server or IP PBX System. In using Voice over Internet Protocol , the PBX communicates with a VoIP Router that has a WAN connection to the Internet where the VoIP Service Provider handles the calls. This set-up serves as a standalone conferencing service for experimental purposes and can be connected later to other groups, using multiple WAN connections. Each robot speaks on behalf of its user to express the problem but serves as sparring partner for the other user , running the PAR process. Reversely, the other robot represents the second user , serving as sparring partner of the first . As soon as the users take over the conversation, the robots keep quiet or take up where they left when human conversation stops. As to the design of the robot's personality, introverts may not like an interruption by a robot, whereas extraverts appreciate more facial cues and expressiveness. Similar personalities between robot and user attract [64] but complementarity attracts as well [65]. A pilot study should determine what the robot's character for introverted older women should be. Apart from being the matchmaker, the robot plays another, rather special, social role. Older adults are short of confidant friends [66] but also seem more satisfied with the friends they still have [67]. A friend is someone you can trust, who will not judge you, who supports you, who has the patience to listen, and who does not claim social space. A social robot can do this by and of itself [47]. A robot is not disturbed by thought or emotion and remains in a constant state of no-mindedness . The robot should play the role of a trusted confidante, advising how to overcome adversity, asking open questions , and inviting self-disclosure. If the user experiences a setback , the robot runs through its coping strategies . If one strategy fails and the user is willing, the robot tries a next. To guide the robot's behaviors it could follow Acceptance and Commitment Therapy [68]. The robot promotes mental flexibility by letting users notice what goes on in their minds, accepting undesired thoughts and feelings as much as the desired ones. The robot will follow emotion regulation behaviors [69] and attempts problem-focused coping and adaptive problem solving [44]: it will mention supportive others and exceptional events, shaping possibilities and self-esteem and shifting focus from problem to ability and to the reappraisal of the situation [27] . The robot checks the loop "Did you improve?" and, if "No," asks to try a different strategy ). Irrespective of the outcome , users engage in making contact with the help of the robot, either to complain about their situation, the robot, or to discuss their new perspective. At least there is content to converse about and a reason to call and become socially connected, which strengthens resilience anyhow. 8.4. Procedure. PAR assumes a group that experiences no setbacks, which may be regarded as 'resilient. ' This is Group1 , who need no robot interference ). The second group ) does perceive an adverse situation and will be exposed to robot intervention. This Group2 is doubled for experimental purposes . Therefore, the target is to have N=96 seniors partake in the experiment. As suggested in Hoorn [59], three moments of measuring ReDeeM are planned. One hour of video surveillance observes participants in their homes. Afterwards, the footage of that one hour preperiod is cut back to about 15 minutes. After the preperiod, a trained interviewer asks open questions for about 10 minutes: "How do you feel? Is life good to you?" This session is recorded as well but the interviewer is not on camera. The preperiod is spent without robot intervention in Group1 whereas Group2 does receive robot treatment. In their preperiod, Group2 trains on handling the robot for the first 15 minutes. Then the robot runs PAR strategies for about 30 minutes after which they spend 15 minutes using the Call-me-Robby! application. With four seniors in the loop and n=64 in Group2, sixteen independent Callme-Robby! sessions will take place. Because we build our own portable IP Phone configuration, participants can stay at home and do not need to travel to the laboratory. As said, each senior is videotaped while they are in the conference call and during the interview thereafter. The shortened video footage of the period preceding the interview and the interview itself are the stimulus materials that are viewed by observers unrelated to the senior to assess the state of mind of the senior, using the ReDeeM structured questionnaire . Both clips and items are presented in pseudo-random order. For N=96, we plan for 150+ observers, viewing 96 clips of 25 minutes each, after which observers fill out the ReDeeM questionnaire . This results in 40 hours of observation time plus 16 hours of assessment, making 56 hours of work spent by one observer after one wave. Because measurement is repeated twice, 3×56=168 hours of work per observer is spent, making a grand total of 25,200 person hours. 8.5. Measurements. The online questionnaire that measures ReDeeM will consist of 7 measurement scales , age, education, and other demographics. The questionnaire will be structured according to [70] and filled out in Qualtrics by the observers to score the videotaped behaviors in the preperiod and during the interview. For Group1, the preperiod is filled with everyday activities; for Group2, it is the robot conference call. Personality is assessed with a shortened version of the revised Eysenck-Personality Questionnaire [71]. For problem-focused coping, I will look into the Coping-Inventory [72]. To measure NeStoR, I adapt the Relatedness scale from the Basic-Need-Satisfaction- questionnaire [30]. For example, "I really like the people I interact with" and "I consider the people I regularly interact with to be my friends" become "She really likes the robot she interacts with" and "She considers the robot she interacts with to be her friend," respectively. This is in combination with items on social presence [49]. For the Social Connectedness scale, I draw on the Inclusion-of-Other-in-the-Self scale [73], Subjective-Closeness-Index-and-Relationship-Closeness-Inventory [74], and Personal-Acquaintance-Measure [75]. I will focus on the quality of relationship rather than frequency of contact or number of people surrounding the older adults. For the assessment of loneliness, I will look into the Loneliness-Rating Scale [76], the De-Jong-Gierveld-Scalesfor-Emotional-and-Social Loneliness [77], the Differential Loneliness Scale [78], and the UCLA-Emotional-versus-Social Loneliness Scales [79]. To evaluate beliefs about Gender Roles, a subset of the Bem-Sex-Role-Inventory will stipulate the participants' gender role as more masculine or feminine, androgynous, or undifferentiated [34]. How well do the women fit into the traditional gender stereotypes ? For resilience as an outcome, a Resilience Scale will be distilled from the Connor-Davidson-Resilience Scale, the Resilience-Scale-for-Adults [80], and the Brief-Resilience-Scale for resilience to anxiety and stress [80]. Control items probe for differences during the preperiod and during the interview itself and for novelty as a covariate, which should diminish towards t3. After scale analysis, a mean index is calculated for each ReDeeM variable for that particular older adult in each wave . From the grand-mean averages, GLM Repeated Measures will estimate before-after effects of the robot intervention on resilience, etc. Multiple regressions test the structure of ReDeeM. --- Results and Discussion Note that the previous sections were meant to instigate a discussion on theory and methods in the study of resilience through robots. After testing is completed , conclusions may be drawn to design a health intervention by a social robot , which would be a novelty in health sciences. In particular, results of the tests of theory , methods , and technology should be informative to the design of an HHRI resilience-loneliness intervention. Systematic reviews of resilience interventions are scarce and mainly address youngsters [60]. However, factors enforcing resilience partly overlap with those countering loneliness: they include adaptive coping, optimism, hope, positive emotions, social support, community involvement, and autonomy [60], factors mentioned also in APA's Resilience Tool Kit. Most resilience interventions attempt to raise positive emotions through, for instance, education, therapy, group activities, screenings, and counseling [60] but none enhances resilience through technology, let alone social robots. Without much difficulty, robot technology can be personalized, a quality that is most wanted in resilience programs for older adults [60]. Systematic reviews of interventions for loneliness and isolation state that effectiveness can be hardly assessed because studies are not so well conducted [82]. I want to fix this problem by using switching replications. Effective intervention should be grounded in theory , provide social activity in groups, activate older adults to partake [82], and emphasize adaptability, community development, and productive engagement [83], all of which are present in Callme-Robby! There are but a few technology-assisted loneliness interventions, most of them involving computer training to communicate with relatives and friends and to search for information. Review papers state that research quality is weak, making the results inconclusive [82,84]. Telephonesupported interventions mainly concern help lines and decrease depression but not loneliness. Telephone circles among women or with informal caretakers that facilitated social support did not help against feelings of isolation, loneliness, or depression [6,82,85]. Probably, those initiatives take care of the abstract information side of treatment but not of the physical presence of a social entity. This is why in application, Call-me-Robby! wishes to improve social skills, social support, social contact, and maladaptive social cognition, which is the most effective remedy against loneliness [86]. A limitation of the current approach is that PAR does not keep record of the development of the resilience process. It does not have a 'mental model, ' let alone a 'theory of mind' of its user. As a second challenge, PAR also may have a model of the user's environment to assess possible crises. It is no trivial task to connect visual and linguistic input to such models and not solely rely on the assessment of the user. --- Conclusions In view of the concerns forwarded by Frennert and Östlund [9], this paper addressed the social role of humanoid robots as confidante and coach in older adult's lives. To develop an effective interaction paradigm in HHRI, the current paper also addressed a new HHRI research methodology for longitudinal study, which unobtrusively involves older adults in the development of their social robots. The paper also provides conceptual clarity in matters that concern older adults the most: loneliness reduction and the reinforcement of resilience. By using the robot as an intermediary in human-human contact, hopefully, I circumvented technological determinism by allowing the formation of a new social construction of humanoid robots [9]. From the explorations in human-humanoid robot interaction with regard to loneliness and resilience support, the following conclusions can be drawn . Older adults have little resilience due to trauma , social setbacks , or organizational distress . They often suffer from loneliness as caused or aggravated by age, social isolation, unfulfilled needs, gender role, and personality. Resilience is a tripartite concept. Resilience encompasses capacity to overcome hardship in a positive manner, a process to engage in interaction and deal with setbacks , and an outcome, which is to establish and maintain high-quality relationships. Humanoid robots can support the problem-focused coping strategies, using the protocol Pathways to Resilience as powered by procedures derived from the FearNot! affective computing system. One of the new research questions is whether humanoid robots address loneliness directly through physical presence or that they take the detour through increasing resilience. With the new measure need satisfaction through robots that question can now be answered. This is because NeStoR's subscales rely on self-determination theory to probe the humanoid side of robots and on presence theory to probe their virtual side. Everything becomes integrated into the brand new Resilience Double Mediation Moderation Model , opening up the possibility of future empirical validation of HHRI in a systematic and hypothesis-driven way with respect to human loneliness reduction and resilience development through humanoid robots. To facilitate that research with fragile older adults at home, a novel, indirect, and observational method was devised, quantizing qualitative samples in a switching-replications design. Finally, as a new way of interaction, an HHRI matchmaking system was proposed that takes the burden of asking for contact from the human user and puts it on the robot, providing the user a safe environment to explore novel human-human relationships without showing or losing face. Looking onward and into the future of human-humanoid robot interaction , many interesting events may occur that will require further examination. In a broader vision than conventional HRI, how as human senders of communication do older adults experience themselves while using a robot to talk to others? What does that do for their feeling of authenticity? Will they 'hide' behind the robot? Will people transgress communicative norms because they can put the blame on a device? To what degree will older adults perceive their robots as genuine social actors and personal representatives? Will they feel the presence of another human being through the presence of the social robot, for example, when the human conversation partner and the user's personal robot cooperate in coaching the user ? What would it be like if the teleconference is enriched with video, something the Pepper robot offers with its torso tablet ? Does it feel as if the robot takes over some of the physical representation of the distant other? Will older adults feel the presence of a social actor when no human is around and the robot displays some form of humanness? Is that different if such a robot is merely televised? What if a social robot takes care of business on their behalves, autonomously? Do people assume their psychological presence in a humanoid machine that takes their place? One step further is how in human-humanoid robot interaction do we design self-directed robot-based education for older adults or let seniors follow robot-led virtual classes ? Will a robot representative feel like an alter ego ? If two robot representatives make out, will that feel as cheating ? General HRI explores the interaction with robots, including those that are not modeled after humans. In HHRI, the advantage is that the humanoid activates scripts of social conduct but not to the extent that humans expect the robot to be fully competent. This provides HHRI with a valuable social 'niche in the middle' [47]. Humanoids provide enough human cues to motivate people into behaviors that are social: the humanoid may assume the role of assistant or consultant and people may feel more resilient and less lonely because of it. Unlike humans, however, humanoids are forgiven if task execution is imperfect, when things come out the wrong way or misunderstandings occur [47]. Humanoids can be used to help people in a natural and intuitive way, yet because they are robots users may find mistaken human conduct funny before it becomes annoying. Communication in HHRI usually looks at similarity between robot and human to find common ground in message transference. However, there is a positive side to otherness. Roboticists and designers may want to build in features that deliberately differ from face-to-face communication , not just for technical reasons but also to downplay the communicative skills of the robot, to lower expectations and hence render more positive net effects of conversational satisfaction. Therefore, a robot as intermediary that brings people into contact as exemplified by the Call-me-Robby! proposal may be an effective new interaction paradigm in HHRI. Older adults may find it acceptable that the robot acts as the matchmaker but by the time its therapeutic capacities are exhausted, it is the other human being that may take over the conversation. As such, a humanoid makes an excellent conversation piece. The effectiveness of the applications and designs in human-humanoid robot interaction and the relevance to our understanding of human behavior all depend on how a humanoid robot communicates and interacts or what could or perhaps should be different from human behavior. These are the new questions of HHRI with respect to artificial relationship formation, once our social robots are welcomed to our lives. --- Conflicts of Interest The author declares that there are no conflicts of interest regarding the publication of this paper.

This paper connects different theories and methods from the social sciences and applies them to human-humanoid robot interaction (HHRI) to explain loneliness reduction and the build-up of resilience in older adults through social robots. It allows for userrelated aspects such as age, social connectedness, gender role, personality, and need satisfaction as well as robot-related aspects, particularly coaching behaviors and communication styles. From these scientific considerations, solutions to design challenges are pinpointed, proposing novel interaction schemes that enhance the feeling of support and companionship. This paper also opens the way to conducting empirical research to examine HHRI-related designs, measuring user experience in HHRI, while suggesting applications in HHRI in various settings, such as coaching and eldercare.

It is estimated that 12,175 children in the United States die from an unintentional injury each year; an additional 9.2 million children will sustain at least one nonfatal injury requiring medical attention annually . In fact, results of a study reviewing patient visits to emergency departments in the United States indicated that unintentional injuries in youth younger than 20 years of age accounted for 39% of emergency department visits between 1993 and 1995 . The financial burden of such injuries is substantial. In 2010, over US$47 billion were spent as a result of unintentional child injuries that resulted in a visit to the emergency department . Such costs suggest that prevention of unintentional childhood injuries should be a public health priority. Indeed, research suggests that a large portion of such injuries are preventable . Several child, family, and caregiver variables have been found to be related to a higher risk of child injury. Boys and children with higher levels of externalizing behavior are significantly more likely to sustain injuries than girls and children with lower levels of externalizing behavior . Several caregiver and family factors have also been found to be related to children's risk for injury. In particular, children from families who live in poverty and children of young mothers with a low level of education are at a higher risk of sustaining unintentional injuries . In addition, children of mothers with mental health problems, such as depression or anxiety, are at a greater risk for injury . For example, Phelan, Khoury, Atherton, and Kahn found that children's risk for medically attended injuries increased as did their mothers' symptoms of depression. Maternal mental health problems may affect mothers' ability to engage in behaviors that keep their children safe . A substantial amount of unintentional injuries occur in the home, suggesting that caregiver behavior may also be an important predictor of children's risk for injury . Caregivers can play a crucial role in preventing injuries by engaging in appropriate injury prevention behaviors, including safety-proofing the environment, and providing adequate levels of supervision. Caregivers who utilize safety devices reduce potential hazards in the environment, and subsequently reduce children's frequency of modifiable injuries . Several studies also suggest that higher levels of maternal supervision can protect children from injuries and that lower levels of supervision lead to an increased likelihood of minor and medically attended injuries . Although supervision is known to play a significant role in childhood unintentional injuries, most extant studies on parental supervision focus on low-risk families. Caregivers in these studies have primarily been upper-middle-class families with low levels of psychopathology and stressors . For example, several studies by Morrongiello and colleagues have examined the relation of supervision to children's injury risk using middle-to upper-income families. In one recent study, Morrongiello, Kane, and Zdzieborski measured maternal reports of supervision and child unintentional injuries among school-aged children through weekly diary recording sheets. Their results indicated that maternal supervision was related to a lower level of injuries ever experienced, and fewer injuries reported during the study. However, these findings were also drawn from a low-risk sample; all families were two-parent households; most of the participants were highly educated; and only 8% of the participants earned less than $40,000 per year. Kuhn and Damashek used a case crossover design to examine the role of proximal maternal supervision in children's risk for injury. Using this design, the investigators predicted children's likelihood of being injured by collecting data on both injury and control conditions in biweekly interviews. The investigators found that children's risk for injury significantly decreased when mothers reported higher levels of supervision, especially when the child was engaging in atypical behaviors. However, again, the sample was relatively low-risk: most participants were married and of middle-to upper-middle-class socioeconomic status. Another recent study, conducted by Schnitzer and colleagues , also used a case crossover design to examine the role of maternal supervision in young children's risk for injury among children who had visited the emergency department. The authors measured three dimensions of supervision, including proximity, attention , and continuity . Results indicated that mothers' proximity to their children predicted greater likelihood of injury. Attention also predicted injury risk, but only for more severe injuries . Although this study did not purposefully recruit at-risk families, the sample was diverse and included a substantial portion of lowincome families. One limitation of this study is that data on control conditions were collected retrospectively; although the investigators interviewed most parents within 1 week of the injury, parents were asked to retrospectively recall what they were doing 1 hour before the injury occurred. This may have limited the accuracy of their reports. In summary, many of the studies examining the role of maternal supervision in children's risk for injury include data from middle-to-upper-income families, and it is unknown whether results from these studies would generalize to high-risk families. One recent methodologically advanced study included a much more diverse sample as well as using a case crossover design to examine proximal risk for injury . However, this study used retrospective reports for control conditions. The goal of the present study was to attempt to replicate findings from previous studies by purposefully recruiting mothers from a low-income, at-risk sample. Similar to research by Damashek and Kuhn and Schnitzer and colleagues , we used a case crossover design and collected data on mothers' proximal levels of supervision prior to both injury events and control conditions. Our study used a prospective approach to collect data on control conditions by sampling minor injuries. --- Methods --- --- Study Design The study used a case crossover design to examine proximal predictors of the occurrence of unintentional child injuries. In case crossover designs, an event is matched to a control condition for each participant. This design differs from a case-control study in which participants with a condition are matched to participants without a condition. However, in a case crossover design, each participant acts as both a "case" and as a "control." Participants "cross back and forth between different periods of risk" . Thus, in this within-subjects design, each subject serves as their own control, and the design inherently controls for between-subjects variability . This design is effective for examining the proximal etiology of transient events versus situations that are more permanent or long-term . Using this design, it is possible to examine whether an event occurred as a result of proximal antecedents by comparing those antecedents to those preceding nonevents . In the present study, each participant reported on times in which their child sustained an injury and times in which their child did not sustain an injury , and we collected data on factors preceding both injury events and noninjury events. Noninjury events were matched to injury events by day and time. Injury events were coded as "1," and noninjury events were coded as "0." We then used conditional logistic regression to predict the likelihood of injury occurrence using our predictor variables of interest . --- Procedures Researchers received referrals from a local home-visiting, family support program serving at-risk families who were referred for maltreatment or for being at risk for negative child outcomes in a mid-sized Midwestern town. Research assistants called interested mothers and set up a consent appointment in mothers' homes. If mothers consented to participate, RAs also administered several baseline questionnaires. When mothers had more than one child in the target age range, RAs used a procedure to randomly select a target child between the ages of 1 and 5. During this initial appointment, mothers were given a pay-as-yougo cell phone to participate in data collection calls. Mothers also received injury recording sheets to be used to record their children's unintentional injuries during the study period. These sheets were used to help mothers recall injuries so that they could report them during phone interviews. Participants also completed a project locator form in which mothers provided their most current, preferred contact information, including cell phone, home address, and contact information for other relatives in the event that the mother was unreachable. Telephone calls that were made on an approximately weekly basis were used to collect information --- Gross annual income Less than $5,000-$9,999 45% $10,000-$19,999 17% $20,000-$24,999 14% $25,999-$29,999 10% $30,000-$54,999 12% $55,000 and higher 2% about injury frequencies as well as antecedents to both injury events and control conditions for a period of approximately eight weeks for each participant. Information about control conditions, or times during which children did not sustain an injury, was collected at the beginning of each data collection call. The RA asked questions about the mother's and child's activity immediately prior to the phone call. Questions included information about who was caring for the child; in what activities the child and mother were each engaged; in what location and how far the child was from the mother, if the mother could see her child, and if she could hear the child. After collecting information about the control condition, the RA then assessed the frequency of injuries that occurred since the prior interview by asking mothers whether any injuries occurred in 19 different injury categories. The RA asked follow-up questions when injuries were reported. The follow-up questions were identical to the questions that were asked regarding control conditions, with the addition of information regarding injury severity . Data collection calls were scheduled to correspond to previous injury events so that we could collect information about control condition events that matched the day and time of previous injury events. This follows the logic of a case crossover design. After each interview, undergraduate RAs scheduled the next interview based on the day and time of the most severe injury that was reported. If the child did not sustain any injuries, the RA used a randomly generated time to schedule the next interview. Mothers participated in a maximum of eight interviews that lasted up to 15 min each. To dissuade mothers from trying to complete data collection calls quickly by underreporting injuries, RAs used filler questionnaires assessing parenting beliefs and practices to fill the duration of the phone call if the interview lasted less than 10 min. Mothers received a $10 gift card for each interview completed and an additional $10 gift card for completing all eight interviews. Mothers also received a $10 gift card for the initial consent appointment. On average, mothers completed 6.12 interviews . The study was approved by the University's Human Subjects Institutional Review Board. --- Measures --- Demographics At baseline, during the initial home visit, mothers completed a demographic questionnaire. --- Maternal Socially Desirable Responding Mothers completed the Marlowe-Crowne Social Desirability Scale at baseline to assess their likelihood to respond in socially desirable ways. The measure consists of 33 true/false items . Mothers responded to questions such as "I have never intensely disliked anyone" and "I like to practice what I teach." The scale has demonstrated strong reliability. It has also been found to be correlated with the Edwards Social Desirability Test as well as the test-taking attitude and lie scales of the Minnesota Multiphasic Personality Inventory . --- Retrospective Reports of Injury Occurrences At baseline, mothers reported the number of minor injuries and medically attended injuries that their child sustained in the 6 months prior to the study. --- Prospective Reports of Injury Occurrences Prospective data on injury occurrence were collected via nearly weekly telephone interviews. RAs used a semi-structured interview to ask mothers whether their children sustained injuries using a list of 19 different injury categories . Mothers reported on injuries that occurred during the period between interviews. For the first interview, mothers were asked about injuries that occurred in the past week. Injuries that mothers indicated lasted at least an hour and were unintentional were included in the present study. For each injury that was reported, the RA asked a series of questions, including day and time of injury; details of the injury; who was in charge of the child at the time; in what activities the child and mother were engaged just prior to the injury, respectively; and their respective locations. --- Injury Severity Scales We assessed children's injury severity using two 5point Likert scales that were developed for the present study . One scale assessed the amount of treatment that children needed as a result of their injury. Mothers were asked "How serious was the injury?" The second scale assessed the degree to which children felt pain or discomfort as a result of the injury by asking, "how much physical pain or discomfort was your child in as a result of the injury?" Measures of Supervision Supervision Coding System. During each telephone interview, RAs asked mothers questions about their and their children's activities and locations for each control condition and injury event. Based on previous research , we assessed three dimensions of supervision, including proximity, visual supervision, and auditory supervision. Thus, RAs asked mothers questions corresponding to their proximity to their children , their ability to see their child , and their ability to hear their child . Using the information that mothers provided, we coded supervision on a 1-5 scale in which 1 was the lowest level of supervision and 5 was the highest for the three domains . We recoded a randomly selected 14% of the interviews , and found that interrater reliability was high for all three supervision scales . Home Observations. In addition, the home visitors from the referring agency completed home observation forms during their routine home visits. These forms were similar to the ones completed by RAs during phone interviews with mothers and included questions about the child's and mother's activities and locations, as well as the mother's proximity, visual, and auditory supervision of the child. Home visitors completed these forms when they arrived at the homes of the mothers based on their observations of the mother and child. These observations were completed on a total of 18 occasions for the entire study. RAs used the information completed by the home visitors to code mothers' supervision using the Supervision Coding System . Parent Supervision Attributes Profile Questionnaire. In addition to the supervision codes, mothers also completed the Parent Supervision Attributes Profile Questionnaire during the initial data collection appointment. Mothers responded to 29 questions on a 5-point Likert scale concerning their supervisory behaviors and beliefs about injury prevention . The PSAPQ assesses four domains: protectiveness, supervision beliefs, risk tolerance, and the role of fate in child safety. Good internal consistency has been demonstrated for each domain. Confirmatory factor analyses also demonstrated strong construct validity of the PSAPQ and these four factors . --- Child Activity Level We assessed child activity level prior to each injury and control condition by asking mothers to respond to a 1-5 Likert scale measuring how active their child was at the time of the injury or control condition . --- Results --- Descriptive Statistics The data were examined for outliers by checking indices of normality and plotting variable distributions; outliers were removed as noted below. The mean number of days between interviews was 7.17 , and mean injury occurrence for each interview period was 0.08 . . Regarding injury severity, mothers typically indicated that their children's injuries were of low seriousness . There was only one injury for which mothers rated the seriousness as a 3, indicating that the child needed medical attention. Seriousness was skewed, such that 99% of the scores were either 1 or 2; thus, we deleted any scores that were higher than 2 for the analyses below. Mothers reported that children generally felt a moderate degree of pain from their injuries . Mean scores on all three scales of the SCS were high. The mean across families was greater than 4 for all of the scales; for proximity, M ¼ 4.49 ; for visual supervision, M ¼ 4.28 ; and for auditory supervision, M ¼ 4.52 . There were very few instances in which proximity and auditory supervision ratings were less than 3 ; thus, observations less than 3 were excluded from analyses below. In addition, there were very few visual supervision ratings less than 2 ; thus, we also excluded these observations. Home visitor ratings of supervision were also high . Mean child activity level was in the somewhat active to active range . Finally, mothers reported few medically attended injuries in the 6 months prior to the study 4 Severe 3 Somewhat severe 2 Minor severity 1 Not at all serious "How much physical pain or discomfort was your child in as a result of the injury?" 5 Extreme pain, seemed unbearable 4 A lot of pain, cried loudly or complained a lot 3 Some pain, cried or complained some 2 A little, complained or cried a little, or whimpered 1 Almost none, didn't even seem to notice SD ¼ 0.61) but reported more minor injuries during this period . Only 2% of the mothers reported more than one medically attended injury in the past 6 months; these observations were excluded for data analyses. Frequency of injury types can be found in Table IV. The most common injuries were falls, cuts and scrapes, and bumps and bruises. --- Bivariate Associations Results of correlations between predictor and outcome variables can be seen in Table V. The three ratings from the SCS were all highly correlated with one another in a positive direction. In addition, auditory supervision and maternal proximity were moderately and positively correlated with the Supervision scale of the PSAPQ, lending validity to the SCS ratings. Auditory supervision was also negatively and moderately associated with the number of medically attended injuries that children sustained in the 6 months prior to the study and was positively associated with mothers' scores on the M-C Social Desirability measure. There was a trend for maternal proximity to be negatively related to retrospective reports of minor child injuries . Mothers' proximity scores were also positively associated with social desirability. Finally, auditory supervision was negatively and moderately correlated with the number of children in the home, and there was a trend for maternal proximity to be related to the number of children in the home in the same direction . Retrospective reports of minor injuries were also moderately and positively associated with the number of children in the home. Mothers' scores on the Supervision scale of the PSAPQ were moderately and negatively associated with retrospective reports of medically attended injuries. Conversely, mothers' risk tolerance scores on the PSAPQ were positively associated with retrospective reports of medically attended injuries. We used t-tests to examine whether proximal predictors of injury occurrence were associated with children's injury likelihood, which was coded as 0 and 1 . Child activity level was significantly higher during injury events versus noninjury events [t ¼ À4.12, p ¼ 0.0001; M ¼ 4.2 for injury events and M ¼ 3.1 for noninjury events], and maternal proximity was significantly lower during injury events versus noninjury events [t ¼ À2.28, p ¼ 0.03, M ¼ 4.1 for injury events and M ¼ 4.6 for noninjury events]. --- Home Visitor Observations of Supervision Home visitor ratings of auditory supervision were strongly associated with our ratings of mothers' auditory supervision . There was a trend for home visitor ratings of proximity to be negatively associated with our ratings of maternal proximity , and ratings of visual supervision were not significantly related to our ratings of visual supervision . Predicting Injury Occurrence As noted above, our primary outcome variable was injury occurrence, rather than injury frequency. Our case crossover design allowed us to predict children's likelihood of injury occurrence by using each participant as both a case and control subject. Thus, mothers reported on antecedents of both injury and noninjury events , and we predicted children's odds of sustaining an injury under particular circumstances. Conditional logistic models were used to predict injury occurrence; these models are recommended for analyzing case crossover data and have been used in similar studies examining child injury occurrence . The predicted outcome was injury or no injury . As these models make within-subjects predictions, between-subjects variables are controlled. We excluded any injuries that were reported to be nonaccidental as well as instances in which children were sleeping . After these exclusions, there were a total of 77 injury and control conditions in the data set. We examined two models. In the first model, we included the three indicators of supervision. In the second model, we controlled for child activity level because activity level has been found to be highly correlated with children's risk for injury in case crossover designs . As can be seen in Table VI, in Model 1, only maternal proximity predicted child injury occurrence, such that higher proximity predicted lower likelihood of injury occurrence. With each 1 point decrease in proximity score, children were five times more likely to sustain an injury. When including children's activity level in the model, activity level was a strong predictor of injury occurrence, such that for each 1 point increase in activity level, children were four times more likely to sustain an injury. With this addition to the model, proximity was no longer a significant predictor of injury occurrence; however, there was a trend for greater visual supervision to predict a lower likelihood of injury occurrence , such that for each 1 point decrease in visual supervision score, children were six times more likely to sustain an injury. --- Predicting Injury Severity We used multilevel modeling to predict our two injury severity outcomes . Multilevel modeling was used because there were several measures of injury severity that were nested within each child, and such models are appropriate for nested data . We used one model to predict the outcome of seriousness, and one model to predict the outcome of pain/discomfort. These models controlled for child age, gender, activity level, and mothers' social desirability scores. Similar to the above analyses, injuries that were not accidental or that occurred while children were sleeping were excluded. In addition, ratings from the SCS for proximity and auditory supervision that were below 3 were excluded, and ratings below 2 on visual supervision were also excluded. Moreover, the outcome variable denoting the perceived seriousness of the injury was significantly skewed toward 1, such that 99% of the scores were either 1 or 2. Thus, we excluded scores greater than 2, and we specified a binary outcome for our analyses. The outcome variable of pain/discomfort followed a more normal distribution and was thus treated as a continuous variable. After these modifications to the data set, there were a total of 72 injuries with severity ratings. As can be seen in Table VII, none of the supervision ratings predicted mothers' perceived seriousness of injuries or children's pain/discomfort. --- Discussion The present study used a prospective case crossover design to examine the relation of maternal supervision to likelihood of injury occurrence and injury severity among low-income families of children aged 1-5. To closely investigate the role of supervisory behaviors in children's likelihood of injury occurrence, we examined three specific types of supervisory behavior: proximity, visual supervision, and auditory supervision. Our case crossover design allowed us to prospectively assess children's likelihood of injury occurrence by comparing supervision preceding injury events to supervision preceding noninjury events . We found that when we did not control for children's activity level prior to the event, maternal proximity strongly predicted lower likelihood of injury occurrence, such that children were more than five times as likely to sustain an injury with each 1 point decrease in the proximity rating. However, when we added child activity level to the model, proximity was no longer a significant predictor, but there was a trend for lower visual supervision to predict greater likelihood of injury occurrence. Auditory supervision was not predictive of injury occurrence in either model. These findings are somewhat consistent with past studies that have examined supervision using similar categories. Schnitzer and colleagues examined proximity, attention , and continuity of supervision. These authors found that proximity was most protective for children, and attention was predictive only for injuries that required inpatient hospitalization. The authors, however, did not control for children's proximal activity level. Our findings that visual supervision, rather than proximity, became predictive of injury occurrence after controlling for child activity level may indicate that it is more difficult for parents to prevent injuries when children are engaged in active behaviors . In other words, being nearby may not be enough to prevent an injury when children are active. Young children can act quickly, and visual supervision in addition to proximity may be needed to avert an injury . Moreover, young children may often surprise their caregivers by engaging in new behaviors as a result of physical and cognitive maturation. Indeed, previous research has found that young children are at a greater risk for injury when they engage in new or unexpected behaviors . None of the supervision ratings predicted injury severity. This is most likely because of the fact that the injuries that mothers reported were very low in severity and limited in frequency, thus limiting our sample size. Indeed, injuries are a low-base-rate phenomenon and are difficult to capture. Given that our sample was at a high risk for injury, it is possible that the mothers in our study underreported injuries, either due to social desirability or due to less diligence in recording injuries. We provided mothers with an injury recording sheet to use between interviews; however, the sheet was only used for 18% of the interviews. Although not a primary focus of this study, we did find a trend for the number of children in the home to be negatively associated to mothers' auditory supervision and proximity on the SCS and marginally related to the Supervision scale of the PSAPQ. It was also positively associated with mothers' reports of minor injuries that occurred in the 6 months prior to the study. These findings suggest that supervising children effectively and preventing injuries become more difficult for women with more children. Previous research examining child maltreatment deaths related to supervision also found that the number of children in the home was related to an increased risk of death from inadequate supervision . Indeed, it makes sense that it is more difficult to spread one's attention among several children. These findings suggest that interventions to prevent injury should try to address barriers that mothers with multiple children face when trying to adequately supervise their children. Validity for our Supervision Rating Scale codes is supported by positive correlations with the Supervision scale of the PSAPQ, which has previously been found to be associated with observational measures of supervision and child injury frequencies . Moreover, auditory supervision was negatively correlated with injuries requiring medical attention in the 6 months prior to the study, and there was a trend for proximity ratings to be negatively correlated with mothers' reports of minor injuries in the 6 months prior to the study. Interestingly, mothers' social desirability scores were positively correlated with our ratings of mothers' proximity and auditory supervision as well as the Supervision scale of the PSAPQ. These findings highlight the need for research on supervision and child injuries to be supplemented by observational measures of maternal supervision and an objective assessment of children's injury frequency. We attempted to collect observational data from home visitors about mothers' supervision of their young children; however, these data were collected sporadically, making our sample size for these analyses quite low. The present study has several methodological strengths. In particular, the present study sampled low-income, at-risk caregivers who were ethnically diverse. This represents an important contribution to the literature because research examining the role of supervision in child injuries primarily includes only middle-to upper-class samples. Another strength of the study is the use of a case crossover design, which allowed us to examine proximal predictors of injuries while controlling for between-subjects differences . Our study was also prospective, and assessed children's injuries on a frequent basis, rather than only relying on retrospective reports of injuries. Finally, our study also used multiple indicators of maternal supervision, which allowed us to examine which types of supervisory behavior are most protective. Moreover, our inclusion of the PSAPQ provided evidence for the validity of our supervision ratings. Despite these strengths, the present study also has some limitations. Our primary method of assessment was via maternal self-report. It is possible that mothers, particularly those who may have a history of referral to child protective services, may be motivated to respond in a socially desirable way. Indeed, we did find that mothers' supervision ratings and their ratings of child injury severity were correlated with their scores on a social desirability measure. However, we did attempt to remedy this limitation by collecting data on mothers' tendency to respond in socially desirable ways and by collecting observational data from home visitors. Unfortunately, our sample size for observational data was small, making it difficult to find significant results. Another limitation is that the maternal-reported measure of child activity level was a measure that has not yet been validated. Furthermore, we did not account for the role of maternal depression in our study. Given the high rate of depression in mothers enrolled in home-visiting services , it is likely that a significant portion of our sample may have had elevated symptoms of depression. Moreover, previous research indicates that maternal depression is a risk factor for child injuries and is associated with decreased supervision . However, as noted in our Methods and Results section, the case crossover design controls for between-subjects differences, such as maternal depression. An additional limitation is that our overall sample size was relatively small; however, collecting detailed data of this nature is time-and resource-intensive. Despite our relatively small sample size, we found meaningful results, which suggests that these findings are likely robust. Unfortunately, we did not have access to the baseline demographic information from which our sample was drawn; however, given the lowincome nature of the sample, the families that we sampled are likely similar to other families being served by the home-visiting agency. Finally, we reported data on minor injuries, rather than medically attended injuries. Collecting detailed prospective information on medically attended injuries is extremely challenging, given that they occur so infrequently. However, several studies have indicated that minor injuries are correlated with children's risk for medically attended injuries and are therefore a reliable proxy . In summary, the present study provided evidence for the important role of supervision in preventing injuries among high-risk children. The study findings suggest that mothers' proximity to children and visual supervision are the most effective ways to prevent injuries among young children, but that visual supervision may be particularly important when children are engaged in high activity levels. The study also suggests that having multiple children in the home makes it more difficult for mothers to supervise their children effectively and prevent unintentional injuries. These findings suggest the need for interventions that can train at-risk caregivers to effectively supervise their young children, particularly in the presence of multiple children. --- A., Klemencic, N., & Corbett, M. . Interactions between child behavior patterns and parent supervision: Implications for children's risk of unintentional injury. Child Development, 79, 627-638. DOI:10.1111/j.1467-8624.2008.01147.x.A m Morrongiello, B. A., Pickett, W., Berg, R. L., et al. . Adult supervision and pediatric injuries in the agricultural worksite. Accident Analysis and Prevention, 40, 1149-1156.

Research indicates that caregiver supervision protects children from unintentional injuries. However, most studies have used upper-income samples, which are at a relatively low risk for injury. Objective This study examined the role of proximal maternal supervision in children's injury occurrence and severity among low-income families. Methods We used a case crossover design and collected data about injury and control conditions for children aged 1-5 in 50 low-income families. Results Higher levels of mothers' proximity to children predicted lower likelihood of injury occurrence. When controlling for child activity level, there was a trend for visual supervision to predict injury occurrence. The number of children in the home was also associated with lower supervision and higher prior injury frequency. Discussion These findings provide evidence for the important role of maternal supervision in preventing unintentional injuries among low-income, at-risk children. Interventions that help at-risk caregivers provide closer supervision for their children are needed.

Introduction The transition from school to work is an important stage for graduates. During this transition, young people need to integrate into the labor market and develop a professional identity. Their practical completion of this transition bodes well for early career success and often predicts their long-term career success. 1,2 However, over the past few years, COVID-19 exacerbates many of the labour market challenges faced by graduating university students. COVID-19 has profoundly impacted various social and economic aspects, resulting in new entrants to the labor market during the epidemic, often more likely to experience job mismatches and precarious employment. The International Labor Organization's recent report World Employment and Social Prospects: Trends to 2023, says that the number of unemployed worldwide is expected to rise slightly to 208 million in 2023, bringing the global unemployment rate to 5.8%. This means there will still be 16 million more people unemployed globally than in the 2019 baseline before the outbreak of the new crown epidemic. Youth unemployment is also a severe problem in China; where according to, Overview of new urban jobs in January-April, a statistical report by the China Development and Reform Commission, the youth unemployment rate reached 20.4% in April 2023, which is the first time more than exceeded 20% since 2018. These recent university graduates are even more affected by labor market instability as a vulnerable group. 3,4 Employment instability not only gives rise to a wide range of "physical and psychological vulnerabilities" 5,6 but also hurt individuals' early and long-term career success. 7 Given the threat of employment instability to the career success of university students, it is of great importance to providing newcomers with the necessary resources to cope with the school-to-work transition to prevent underemployment, long-term unemployment, and negative impacts on their future careers. Therefore, more academic, policy-level, and educational attention is needed to understand better and increase graduates' chances of entering the labor market and early career success. --- Precarious Employment on Career Success Precarious employment is often defined as work that accumulates several unfavorable characteristics of employment quality, such as job insecurity , inadequate earnings and limited rights and protections , are more common among disadvantaged or vulnerable groups. [8][9][10] Subjective career success refers to the degree to which employees are subjectively satisfied with their occupation, including enjoyment of work and pride in achievement. It is a positive psychology from work experience. 11,12 Subjective career success strongly impacts employees' happiness and personal self-esteem. When employees have high subjective career success, their happiness and personal self-esteem in the organization also increase substantially. Likewise, subjective career success enhances employees' loyalty to the business organization and improves their performance and motivation to continue to develop. 13 Employees' subjective career success is important for them and the company's management. However, employment instability brings more change and uncertainty to individual career development, making people feel more threatened in their daily work. 14 This instability may, in turn, create psychological stress for individuals and negatively influence their work and career-related cognitive decisions, for example, thereby reducing their perception of subjective career success. 15,16 In particular, newcomers entering the labor market during the COVID-19 pandemic are more likely to become more precarious. They are likely to face unemployment without being formally dismissed or even be subject to unfair treatment, abuse, and exploitation. This directly leads to the failure of their first job in the labor market and hinders their future career outcomes and professional success. 7,[17][18][19][20] On this basis, we propose the first hypothesis: H1: Precarious employment can negatively predict students' career success. --- The Mediation Effect of Financial Stress For many people, money is an extremely important resource used to obtain other resources needed for survival. It is a source of self-worth and an indicator of personal achievement. 21 Financial stress occurs when resources such as money are unavailable to meet an individual's needs. 22 The sources of financial stress for many college students are multifaceted. They may include living expenses, tuition, student loan debt, work-school-life balance, financial pressures from family, and uncertain employment after graduation. [23][24][25] Indeed, any threat to finances can lead to stress. Financial inadequacy, in this case, may be more likely to lead to higher financial stress for individuals than actual financial losses. 26,27 Low wages and underpayment are recognized features of employment insecurity. Particularly for many individuals in precarious employment, financial stress, poverty, and material deprivation are critical pathways to poor career progression. 8,28 More specifically, stress triggered by the perceived inability to meet financial obligations as a stressor may be the most important factor affecting an individual's career performance. 29 This is confirmed by recent studies that, following the COVID-19 outbreak, employees in precarious jobs tend to suffer from high financial stress and anxiety and experience high burnout and low life satisfaction, which can have a significant impact on their health and work. [30][31][32][33] In addition, previous research has suggested that financial stress may be a barrier that may prevent individuals from investing time in career engagement and professional competence. 34 For example, the Job Demands-Resources model states that finances are an essential need and that financial inadequacy or financial insecurity exacerbates the negative consequences resulting from the depletion of physical and mental resources. This continuous state of lack is closely related to employee disengagement. 35 Lack of resources is the primary antecedent that leads to lower-thanexpected levels of employee engagement. 36 Therefore, we argue that employment instability can hinder college students' career development by increasing financial stress. Both unmet financial needs/lack of financial resources may lead to college students' early job goals falling short of expectations and, thus, early career success is hindered. Based on previous evidence, we propose the following hypothesis. H2: Financial stress mediates the relationship between precarious employment and career success. The Mediation Effect of Occupational Self-Efficacy Social Cognitive Career Theory has been widely used as a specific theory for the study of career interest, choice, performance, and satisfaction. 37,38 SCCT elucidates the relationship between the influence of career domains and career development. [38][39][40] It focuses on an individual's ability to shape career behavior and highlights the triadic interaction between key person variables: self-efficacy, outcome expectations, and career domain-specific goals. 39 Self-efficacy is considered to be individuals' beliefs about their ability to master certain tasks and is one of the most studied psychosocial variables associated with STWT, demonstrating the role of these beliefs as predictors of STWT success. 7,37,41 In the context of this study, occupational domain self-efficacy is "the beliefs of individuals in the occupational domain about their ability to perform the tasks and demands of the occupation" and is "considered to be all content-related self-efficacy across an individual's occupational domain". 42,43 According to the SCCT, the core elements driving career behavior are self-efficacy, outcome expectations, and goal selection. 38 The chain between these elements further addresses how individuals achieve career development success. In recent years, explorations of the mechanisms influencing subjective career success have broken away from the traditional focus on objective competencies and placed greater emphasis on the key mediating role played by social cognitive variables, emphasizing the importance of career self-efficacy in influencing individual performance, achievement, and career development. 39 In the context of precarious employment, an individual's attitudes and beliefs about their abilities can have a significant impact on the extent of career development. 44 Many previous studies have also confirmed that precarious employment can diminish occupational self-efficacy, reduce social integration, and more broadly affect individuals' career development, including subjective and objective career success. 42,45 Therefore, we suggest that employment instability may indirectly affect early subjective career success by reducing college students' career self-efficacy. H3: Occupational self-efficacy mediates the relationship between precarious employment and career success. --- The Chain Mediating Effect of Financial Stress and Occupational Self-Efficacy Previous research has shown that a wide range of factors influence levels of self-efficacy, including but not limited to individual differences and self-perceptions, situational cues, and learning experiences. 38,46 The SCCT emphasizes how situational barriers may facilitate or hinder career development and potentially impact career self-efficacy, interests, and goals. 47 Previous research on barriers to career decision-making supports the argument that individuals' self-efficacy to pursue career-related tasks is significantly reduced when they perceive significant barriers to their career ambitions. 48,49 Among these, significant barriers may be the lack of financial resources or conflicts related to family needs, for example, as such barriers may prompt them to reassess their occupational abilities and lead to lower occupational self-efficacy. 50 Many studies on adult individuals have shown that feelings of security about occupations promote occupational selfefficacy, while financial stress reduces occupational self-efficacy. [51][52][53] For example, Some scholars suggest that financial stress has a direct negative relationship with occupational self-efficacy and an indirect negative relationship with job search outcome expectations and goals. 54 Financial stress may act as a harmful form of feedback that directly indicates poor performance in the employment arena. 50 This is consistent with social cognitive mechanisms that emphasize that when individuals face financial stress, they may internalize their difficulties as evidence of a history of failure, thereby reducing career-related self-efficacy. 55 Based on previous research, we know that financial stress can have a negative impact on individuals' career self-efficacy. Given the possible association between higher financial stress and career self-efficacy, we believe examining the possible chain mediating effects of financial stress and career self-efficacy in relation to employment instability and subjective career success is necessary. Therefore, we propose the following hypothesis: H3: Financial stress and occupational self-efficacy play a chain mediating role in the relationship between employment insecurity and subjective career success, and financial stress is negatively related to occupational self-efficacy. --- The Moderating Effect of Employability The development of employability is considered to play a crucial role in graduates' career success. 56 Employability refers to the chances of an individual finding a job in the internal and external labor market. 57 As highlighted by several studies, career success depends on continuous learning, adaptation to new job demands or shifts in expertise, and acquiring skills through career changes in different organizational settings. 58 Empirical research suggests that one way to facilitate successful school-to -work transitions is through appropriate preparation for employment, as better practice can help individuals to successfully search for and find jobs and improve employability. [59][60][61][62][63] Notably, upon entering the labor market, young people may often experience a period of employment volatility. [64][65][66] Their judgment of their ability to remain employed during these fluctuations is crucial to their job integration. This is because, in this critical period, employability has been shown to reduce the risk of unemployment and job insecurity and maintain their confidence that they can effectively engage in career development. Those who perceive themselves as more employable experience less financial stress than those less employable. 67 It is, therefore, reasonable to assume that university students perceptions of employability can reduce financial stress caused by employment instability and low career self-efficacy, positively contributing to early and long-term career success. 7,68,69 Based on the above, we propose that: H5a: Employability moderates the relationship between precarious employment and financial stress H5b: Employability moderates the relationship between precarious employment and occupational self-efficacy H5c: Employability moderates the relationship between precarious employment and career success. --- Current Study Previous research has established the importance of a smooth transition from school to work for early and long-term career success. However, until now, we have lacked a thorough understanding of how employability contributes to the successful transition from school to work for graduates. At the same time, the vast majority of empirical research to date has remained less focused on the actual transition itself. The core elements identified by SCCT as driving career/employment behavior are self-efficacy, outcome expectations, and goal choice. 38 The chain between these elements further addresses how individuals achieve career development success. Therefore, SCCT forms the theoretical basis for this study. 38,70,71 This study helps to fill in previous relevant research and thus provides insights into their actual transition into the labor market. Key objectives include: examining how employment instability experienced by college students transitioning from school to work acts on early career outcomes, ie, early subjective career success, through financial stress and career self-efficacy, based on a model of social cognitive career theory. Given the strong relationship between employability and career success in today's employment environment, we believe that introducing an examination of employability will help to reveal the mechanisms at play between employment instability and subjective career success. Answer the question that if graduates are actively building their careers in terms of employability, can they achieve a smooth transition leading to early career success? The research framework of this study is shown in Figure 1. --- Materials and Methods Participants The traditional employment pathway for Chinese university students is to start looking for a job in the labor market between the summer holidays of their third year of university and their senior year . If this goes well, they can generally start an internship with the company and stay on after graduation. This stage represents the transition from school to work for many university students. Students from 5 universities in Harbin, China, were invited to participate in this study from May to July 2022. The participant selection criteria were fourth-year university students who were in internships and planned to enter the workforce after graduation. We advertised and recruited volunteers in schools, and if students were willing to participate in the study, the research assistant distributed questionnaires via social media . Before the survey, the research assistant explained to all participants the specific purpose of the study and the detailed description of the questionnaire and ensured that the privacy of personal information in the questionnaire would be protected. All participants completed the questionnaire voluntarily and were compensated appropriately. A total of 992 documents were distributed for this study. After excluding the sample of missing responses, the final result was 967 valid questionnaires, whose average age was 22.036 ± 1.451 years, 561 male students , 508 from science disciplines , who had been working for an average of 3.683 ± 1.318 months. --- Measures Precarious Employment The employment precarious Scale is a theory-based multidimensional measurement tool to assess employment instability. 72 It consists of 23-item 0-4 scale divided into six dimensions: temporariness , deprivation of power, worker vulnerability, material rewards , workplace rights, and the ability to exercise these rights. 72 The scale is calculated by first calculating the mean value for each dimension and subsequently calculating the mean value for each dimension, where higher values indicate higher levels of employment instability. The Cronbach's Alpha of this scale is 0.938. --- Career Success The Subjective Occupational Success Scale measures occupational success developed by Greenhaus. 73 The 5-item Subjective Career Success Scale measures individuals' perceptions of their financial/non-financial goals and achievements and their satisfaction with them. Example items include, "I am satisfied with my success in my career" and "I am satisfied with the progress I have made towards my income goals". Items are rated on a five-point scale from 1 = strongly disagree to 5 = strongly agree. The Cronbach's Alpha of this scale is 0.797. --- Financial Stress The 7-item Financial Anxiety Scale is based primarily on items from the GAD-7 and is adapted to financial stress . 22 Answers were shown to be frequent on a 7-point scale , with higher mean scores indicating more financial stress. The Cronbach's Alpha of this scale is 0.859. --- Occupational Self-Efficacy Using Schyns and Collani's professional self-efficacy, a total of nine questions were included . 74 The questionnaire is based on a 5-point scale, . The higher the score represents the greater the sense of professional self-efficacy. The Cronbach's Alpha of this scale is 0.895. --- Employability Van Dam's 6-item employability scale is applied to graduates, and it assesses the activities individuals undertake to improve and maintain their employability, such as extending their work experience and engaging in training activities . 75 Using a 4-point score ranging from 1 = completely disagree to 4 = completely agree. The Cronbach's Alpha of this scale is 0.846. --- Statistical Analysis The statistical analysis for this study was conducted using SPSS 24.0 and the Process v3.3 plug-in. Firstly, the basic characteristics of our sample and the relationships between the main variables were analyzed. Secondly, we tested the chain mediating effect of financial stress and occupational self-efficacy between precarious employment and occupational success. Finally, we examined the moderating role of employability. Confidence intervals were calculated for each pathway using the Bootstrap method to avoid bias introduced by the sample distribution. All the main variables were z-score standardized in the second and third steps of the analysis. --- Results --- Preliminary Analysis The results of preliminary analyses, including descriptive statistics and Pearson correlation coefficients, were showed in Table 1. The results showed that college students who scored high levels of career success were more likely to have low levels of precarious employment and financial stress and high levels of occupational self-efficacy . Besides, precarious employment was positively associated with financial stress and negatively associated with occupational self-efficacy . In addition, employability was positively associated with career success and occupational self-efficacy , but was negatively associated with precarious employment and financial stress . --- Examination of the Mediating Effects of Financial Stress and Occupational Self-Efficacy Hypothesis 1~4 predicted that the relationship between precarious employment, career success, financial stress and occupational self-efficacy. We used Model 6 of the PROCESS macro to examine these hypotheses, and the results were presented in Table 2. 76 As Model 1 showed that precarious employment was negatively associated with career success . Therefore, H1 has supported. Model 2 and model 3 showed that precarious employment was positively associated with financial stress and positively associated with occupational self-efficacy . Model 4 verified financial stress was negative associated with career success , and occupational self-efficacy was positive associated with career success , Therefore, H2 and H3 has supported. In addition, model 3 verified the negative relation between financial stress on occupational self-efficacy , Therefore, H4 has supported. The results of bias-corrected percentile bootstrap method confirmed above inferences. The bootstrap mediated effect estimate for financial stress is -0.078 , the bootstrap mediated effect estimate for occupational self-efficacy is -0.029 , and the bootstrap chain mediated effect estimate for financial stress and occupational self-efficacy is -0.005 . Since the 95%BootCIs for each mediating effect did not contain 0, they were all significant. --- Examination of the Moderating Effect of Employability Hypothesis 5a~c predicted that employability would moderate the indirect and direct pathways between precarious employment and career success. We used Model 85 of PROCESS macro to examine these hypotheses. 77 The results were presented in Table 3. Model 1 showed that precarious employment was positively associated with financial stress , but the regression coefficient of the interaction term of precarious employment and employability was not significant --- 2333 . Therefore, employability did not significantly moderate the relationship between precarious employment and financial stress. So, H5a has not supported. Model 2 showed that the regression coefficient of the interaction term of precarious employment and employability was significant . Thus, the pathway between precarious employment and occupational self-efficacy was moderated by employability. Simple slope tests showed that for the students with high levels of employability, the negative relation between precarious employment and occupational self-efficacy was weaker than low levels one . We use a simple slope figure to reflect the change in the relationship between precarious employment and occupational self-efficacy under different levels of employability . So, H5b has supported. Model 3 showed that the regression coefficient of the interaction term of precarious employment and employability was significant . So, the pathway between precarious employment and career success was moderated by employability. It meant that for the students with high levels of employability, the negative relation between precarious employment and career success was weaker than low levels one . Again, we use a simple slope figure to reflect the change in the relationship between precarious employment and career success under different levels of employability . So, H5c has supported. --- Discussion In this study, we examined the mechanisms underlying the role of employment instability on subjective career success during the school-to-work transition of university students based on the social cognitive career theory. The findings highlight the critical role of employment instability in predicting career outcomes during the school-to-work transition. Indeed, employment instability hinders university graduates' smooth transition from school to the labor market and affects their subjective career success. Second, precarious employment can affect students' career success by mediating the effects of increased financial stress and reduced career self-efficacy. At the same time, financial stress may also cause university students' early job goals to fall short of expectations, thereby reducing their career self-efficacy, putting a damper on early career success. [51][52][53] Finally, the findings confirm that employability can play a crucial role in graduates' career success as a personal resource in the context of employment instability, with high employability --- 2334 implying the maintenance of confidence that they can engage effectively in their careers as well as self-efficacy, and positive protection against subjective career success. Firstly, the associations found in our study are consistent with the direction of previous scientific evidence. When graduates perceive employment instability, this uncertainty and insecurity directly affects their career development. Specifically, when graduates are dissatisfied with their career status, the achievement of their career goals, and their career prospects, they are more likely to believe that their career development is hindered, and affect early career success. 78 However, for recent graduates, the economic crisis caused by COVID-19 has led to a significant deterioration in their working conditions and increased job uncertainty, gradually causing them to lose control of their careers. This job instability has been shown to hinder their future career expectations and the effects may be irreversible. 79 Not surprisingly, precarious employment is rising for all graduates in China . In 2022 China's university graduates will account for around 80% of the new labor force, almost equal to the number of new urban jobs. Thus, in recent years, the employment of Chinese university students has become difficult, with a large number of delayed employment or even non-employment, which leads to the employment situation of college students becoming more and more severe. Second, our findings further support the mediating role of financial stress and career self-efficacy between precarious employment and career success during school-to-work transition period and that financial stress can directly influence career self-efficacy. Unstable employment can affect subjective career success by increasing students' financial stress and decreasing career self-efficacy. Early career stability is crucial for university students leaving school and entering the workforce. Unstable employment is often accompanied by inadequate income, low job security, and lack of power, leading to higher financial stress and lower job beliefs and drives, ultimately reducing their perceptions of career success. 8,34,42,45 Also, it has been confirmed that economic stress reduces career self-efficacy among college students. 50,54 From a mastery perspective, financial resources can indicate an individual's level of achievement at work. 80 A lack of financial resources may limit an individual's ability to develop a career. 34 Thus, financial stress caused by a lack of financial resources can lead to lower individual occupational self-efficacy and act as an environmental barrier to occupational success. This also confirms the findings of the school-to-work transition and the study of barriers to career decisionmaking. On the one hand, a lack of financial resources may hinder individuals' career development, and career-related self-efficacy may be significantly reduced. 48,49 On the other hand, financial resources can indicate an individual's level of achievement in the workplace, and a lack of financial resources can limit an individual's ability to develop career skills and move to the next job. 34 In summary, an individual's income and financial situation are the most important factors influencing occupational self-efficacy. 80 We add strong evidence for school-to-work transition period by introducing employability as a moderating factor between precarious employment and subjective career success. More specifically, the findings find that graduates' employability is an important protective factor for their early career success during the challenging transition from education to the labor market, reducing the adverse effects of precarious employment on occupational self-efficacy and career success. It is crucial for graduates to develop their employability skills early on. 79,81 The success of university students' employability development efforts during their education may be a powerful contextual resource that can trigger young people to actively build their careers. 82 This is because providing employability skills may make them more resilient in the face of such large career shocks, leading to a smooth transition to work. 56,83 Specifically, graduates who actively build their careers in terms of employability can achieve a smooth transition leading to early career success, as perceptions of employability reflect career-related self-efficacy. 56 High levels of employability reflect individuals' beliefs about their ability to perform behaviors that will lead to desired outcomes . 37 Similarly, as employability as a personal resource tends to be associated with psychological resilience, individuals with high levels of personal resources are perceived to have higher levels of control. This control can help them to cope more effectively with risks and disadvantages such as those they face and to reduce the negative impact of such risks on their career development . Thus, equipping university students with higher levels of employability can also help graduates succeed as they prepare for the transition to work in a period of increased employment uncertainty. This finding is particularly agreed upon in the face of the COVID-19 pandemic, which reduces graduates' risk of greater unemployment and long-term career disadvantage. 4 Similarly, graduates' high awareness of their employability helps protect them from negative outcomes such as reduced career self-efficacy and stunted career progression due to precarious employment. The findings of the study further emphasize the importance of personal resources on school-to-work transition. --- Limitation Although the relationship between employment instability and college students' subjective career success has been explored, several significant limitations remain. First, our SCCT-based model is not exhaustive but rather highlights key factors in the school-to-work transition process that influence college students' subjective career success. Another potentially important personal and contextual factors deserve further attention. Similarly, many studies have highlighted the important role of social support in the STWT process, and individuals who have networks of social connections that provide them with material and emotional support tend to sail through the period. 84 Yet the proximal mechanisms behind the relationship between different types of social support and subjective career success remain under-explored. A more accurate understanding of how other social supports, if acting on college students' work overload, could help future career development. Secondly, given that the time of investigation in this study was still during the COVID-19 pandemic, this may have some implications for participants' work experiences. Finally, quantitative research can examine causal relationships between model factors, while qualitative research can explore underlying processes and challenges vulnerable groups face. Our study population of a sample of university graduates limits the ability to generalize the findings of this study to all groups with precarious employment. Future research will require a broader and more representative sample. --- Conclusion Overall, the findings of this study highlight the importance of employment stability during the school-to-work transition for the early career success of university students. First, we find that the increased employment instability faced during the school-to-work transition has a significant negative impact on young people's early career success. Second, the findings suggest that unstable employment not only leads to higher financial stress among university students but also reduces career self-efficacy, which in turn affects their perceptions of early subjective career success. Higher financial stress also reduces their career self-efficacy. Importantly, our results confirm that employability is crucial for a smooth school-to-work transition and future career development. Therefore, education systems and businesses need to help young people think about career paths, and employability can be used as an intervention to guide actions that contribute to the early career success of university students. 85,86 Human resources policies can focus on developing graduates' employability-related skills and growing practices that enhance their employability. --- Ethics Approval The Academic Committee of the Northeast Agricultural University approved this study. Participants were informed of the study, and consent was obtained before the start of the study. --- Disclosure The authors report no conflicts of interest in this work.

The transition from school to work is an important stage in the career development of university students, and precarious employment during this period can significantly impact their early career success. In today's unstable employment environment, this study examines how employment instability during the transition from school to work directly and indirectly affects college students' subjective career success. This contributes to a thorough understanding of this transitional period and provides university students with the necessary resources to cope with a smooth transition from school to work. Patients and Methods: We recruited senior students at five universities in Harbin, China, from May to July 2022. After obtaining participants' consent, questionnaires were distributed via social media, resulting in 967 valid questionnaires. Based on this sample, we examined the chain mediating effect of financial stress and occupational self-efficacy in the association between precarious employment and career success and the moderating effect of employability.The study found that precarious employment hurts career success and can also affect career success by increasing financial stress and decreasing occupational self-efficacy among college students. At the same time, financial stress can also decrease students' self-efficacy. Finally, employability can reduce the adverse effects of precarious employment on career success and occupational selfefficacy.The link between employment instability and subjective career success during the transition from school to work has been demonstrated for university students. Employment instability not only increases college students' financial stress but also reduces career self-efficacy, which in turn affects college students' perceptions of early subjective career success. Importantly, employability plays a positive role in the smooth school-to-work transition and subjective career success of university students.

Introduction The term "dental anxiety" is often used as a blanket term to describe all the different types of dental fears and phobias. 1 This disorder has been recognized as a potential behavioral management problem. 2 Despite the evolution of pediatric dentistry, preventing or intercepting dental fear or anxiety at the outset remains a challenge. 3 Identifying high levels of anxiety is important for everyone involved in pediatric dental care. 4 This is important so that the staff can anticipate negative behaviors and reactions and minimize the need for further measures to be implemented to make the dental treatment less problematic. 5 Among the psychometric methods available for assessing dental anxiety and fear in children and adolescents, the Children's Fear Survey Schedule-Dental Subscale is the most widely used. 6 This scale was developed by Scherer and Nakamura 7 and modified by Cuthbert and Malamed. 8 It has been validated by several countries, including Sweden, 9 Greece, 10 China, 11 Italy, 12 Saudi Arabia, 4 and Brazil. 13 Dental anxiety is not considered to be stable, 14 since some factors may influence it over time, such as behavior during dental treatment and some components of dental history, including dental caries experience and types of previous dental treatments received. 14,15 Dental anxiety can create a vicious cycle in which avoidance and delay of the dental visit can deteriorate oral health, leading to a greater need for complex treatments rather than for prevention appointments. 16 Although the relationship between dental caries and dental anxiety is controversial, 17 some authors have reported a positive association between them, 18,19 primarily when permanent teeth are involved. 17 However, these observed associations have previously considered the severity or the extent of lesions involved. 20 Other factors may be related to dental anxiety in children, such as appointment history. 14 The types of dental treatments carried out during previous dental visits play a significant role in childrens' dental anxiety levels. 14 Children who previously underwent invasive procedures, such as extraction, show significantly higher levels of dental anxiety compared to those without these experiences. Greater levels of dental anxiety have also been reported in children who did not have regular dental visits compared to those who had regular dental visits. 21 The first dental appointment appears to influence childrens' dental anxiety levels, as children who have already had their first dental visit often present less dental anxiety. 19 Previous studies have indicated that socioeconomic status could be a determinant factor for dental anxiety, as children in the lowest socioeconomic groups presented higher levels of dental anxiety. 22 Although the relationship between dental anxiety and these factors has been reported in many regions globally, these associations remain unclear among Brazilian pediatric patients. Thus, the present study aims to observe the dental anxiety profile and identify the effect exerted by socioeconomic and dental data factors in a group of Brazilian pediatric patients aged 7-12 years old who sought dental care. --- Methodology A cross-sectional study design was used and was guided by the checklist developed by Strengthening the Reporting of Observational Studies in Epidemiology . 23 The study was approved by the Research Ethics Committee of the Clementino Fraga Filho Hospital of the Universidade Federal do Rio de Janeiro . Pediatric patients and guardians received information about the research and its purpose, and upon acceptance, signed assent and consent forms. --- Sample definition The sample size was determined based on the prevalence of dental fear in clinical settings presented by Cademartori et al. 13 The minimum sample size estimated was calculated assuming set parameters: a confidence level of 95%; a dental fear/anxiety prevalence of 32% based on B-CFSS-DS scores; 13 a margin of error of 3%; and the sample population of 128. As the study was conducted via interviews, an additional parameter regarding non-responses was not included. A minimum sample size of 113 individuals was estimated. All the enrolled participants were selected from February to December 2019 from the Pediatric Dentistry Clinic of the Dental School at the UFRJ, Brazil. The eligibility criteria included pediatric patients of both sexes, aged 7-12 years, who were not cognitively or systemically compromised, and whose guardians were accompanying them at the time of the research. --- Sociodemographic and socioeconomic data Before starting the interview, each participants' guardian answered a questionnaire to collect sociodemographic data, such as address, sex, age, and socioeconomic data, such as family income , education level , and child's school type . Family income was categorized based on the BMW, which corresponds to approximately 246 USD/month. Family incomes less than or equal to 3 minimum wages were characterized as low income . 24 Pediatric patients dental anxiety assessment using the CFSS-DS Before dental care, in order to capture accurate dental anxiety levels based on the environment inside the clinic, each child answered the questionnaire, which was carried out by a single interviewer . This was done to avoid variations in the questions asked. The interviewer was not in dental care attire and did not identify himself as a dentist to avoid influencing the participants' responses. The CFSS-DS is a dental-specific measure that assesses fear and anxiety using 15 dental-related situations and treatments . 25 The scores were measured on a five-point scale of fear . The sum of all response scores can range from 15 to 75. 8 The Brazilian version of CFSS-DS was used, and the presence of dental anxiety was assumed to be confirmed when scores equal to or greater than 33 were presented. 13 --- Participants' dental data Three aspects were integrated into the collection of participants' dental data: their history of dental appointments, previous dental procedures received, and caries experience. The history of dental appointments was assessed using the information provided by the guardian. Guardians were asked whether the current visit was the child's first dental appointment, regardless of whether it was at the Clinic of the Dental School or at another service. The answer options were yes or no. When the answer to the question was "no" a follow-up question was asked regarding which dental procedures the child had already received . As these procedures could have been carried out in other dental offices, there was no possibility of obtaining this data. Therefore, the guardian also provided this information. Caries experience was evaluated through clinical examination by a trained operator, under a dental chair reflector, using single-use tongue depressors. The decayed, missed, and filled teeth index for primary teeth and, DMFT for permanent teeth based on World Health Organization criteria 26 were used to register the caries experience. However, the experience of caries was categorized as the presence or absence of caries lesions, missed tooth by caries or some restoration, instead of the total value of the index. --- Statistical analysis Statistical analysis was performed using the IBM SPSS ® software, version 21.0 . Descriptive statistics were used to express each result as a mean, median, and standard deviation . To optimize the analysis, the median of the participants' age was obtained by dividing them into two age groups . The normality of data was assessed using the Shapiro-Wilk test. However, normality was not verified, so analysis proceeded using nonparametric statistics. Dental anxiety was assessed based on whether or not participants' B-CFSS-DS scores were equal to or greater than 33. Chi-squared tests were used to identify the relationships between dental anxiety and family income ; guardians' education level ; child's school type ; history of dental appointments ; previous treatment and caries experience . To analyze the distribution of dental anxiety scores among these variables, the Mann-Whitney U test was used. The level of significance was set at 5%. --- Results The sample of the study comprised 120 pediatric patients, with a median age of 9 years old . The mean of B-CFSS-DS scores of the sample was 30.1 ± 9.2, with a range of 15 to 62. Out of all participants, 39.2% presented with dental anxiety based on their B-CFSS-DS scores. The distribution of participants across the study variables is shown in Table 1. Table 2 shows the results of the analysis between the study variables and the presence or absence of dental anxiety. There was a statistically significant association between dental anxiety and family income and patients who had not received endodontic treatment . The B-CFSS-DS scores per item and total scores were compared between sexes and age groups. Boys had a higher mean score for the item "Doctors", while girls had a higher mean score for the item "Having a stranger touch you" . Children aged 7-9 years presented higher mean scores overall, and for items such as "Dentists", "Having someone examine your mouth", "Having somebody put instruments in your mouth", and "Having the nurse clean your teeth" . These results are presented in Table 3. Regarding the distribution of B-CFSS-DS scores among the socioeconomic assessment items, family income was not considered significant, although it came close . Guardian education level and child's school type did not influence B-CFSS-DS scores . These results are presented in Table 4. Regarding dental data, higher dental anxiety scores were found in patients who did not receive endodontic treatment . No significant relationship was found between B-CFSS-DS scores and a history of dental appointments or caries experience . These results are presented in Table 5. --- Discussion This study evaluated dental anxiety in pediatric patients aged 7-12 and aimed to identify the effect exerted by socioeconomic and dental data. Although other dental anxiety surveys have previously been conducted in Brazil, this is the first study using the B-CFSS-DS following its validation by Cademartori et al. 13 Table 1. Distribution of participants between the variables. In several previous surveys that used the CFSS-DS to assess dental anxiety, results were expressed as scores, with a cut-off point used to define the presence of anxiety. Most studies used the level of ≤ 38 as a cut-off point for dental anxiety definition. 27 In Brazil, the cut-off point recommended for use with the B-CFSS-DS is ≥ 33. 13 Based on this, the prevalence of anxiety in the selected sample was determined to be 39.2%. As different instruments are used to evaluate dental anxiety, only results from studies that used the CFSS-DS were considered comparable with the current results. A systematic review identified that prevalence rates in other countries ranged from 10-21.2%. 27 In Brazil, the prevalence has previously been reported as between 32-33%. 13 The use of a lower cut-off point to identify anxious children when using the B-CFSS-DS may contribute to this higher prevalence. However, as there was no consensus regarding the appropriate cut-off point between previous studies, the value considered appropriate for the Brazilian sample was used. Differences in factors, such as sex, age, country of origin, and the cut-off point used for identification of dental anxiety in each study may contribute to the variations seen in reported prevalences. 27 The mean CFSS-DS scores in other countries ranged from 21.0 in China 11 to 34.2 in the United States. 28 The mean score of the CFSS-DS in the present study was 30.1, similar to the results found in Italy 12 and with another study from Brazil . 13 The large variations between different countries and small variations between applications in the same country reinforce the idea that culture could be responsible for the different values. In the present study, the B-CFSS-DS was used to determine dental anxiety while the child was in the clinical setting. Previous studies, including the study that validated the B-CFSS-DS, 13,20 have applied the instrument outside of the clinic setting, such as in a waiting room. This change was made in the present study due to the possibility that dental anxiety is milder during the waiting period, where there is a lack of experimentation in the care environment. Thus, it was assumed that evaluation outside of the clinical environment would be a possible mitigation for the dental anxiety presented. Greater fidelity was assumed when dental anxiety was evaluated at the place of care. Previous studies have observed higher dental anxiety scores in girls, 11 thought to be due to their tendency to show their feelings, unlike boys who may deny their fear. 15,29 However, no statistically significant difference in total score between sexes was found in the present study, as well as in another. 10 However, the comparison of CFSS-DS mean scores on each item showed that boys had a higher mean score for the item "Doctors", while the girls had higher mean scores for the "Having a stranger touch you". This could be explained by the difference in perceptions and sensitivity between boys and girls regarding the situations. The younger age group had significantly higher anxiety total scores, which has been found in previous studies. 12 Furthermore, the younger age group had higher mean scores for the items "Dentists", "Having someone examine your mouth", "Having somebody put instruments in your mouth", and "Having the nurse clean your teeth". It has been reported that dental anxiety may decrease with age. 30 This is thought to be due to cognitive ability development, which provides children with adequate coping styles and increases their ability to understand the explanations given by their dentists, thereby reducing their dental anxiety. 20,31 Pediatric patients from low-income families presented higher dental anxiety levels, which has been previously reported by Dogan et al. 22 This suggests that socioeconomic status could be a determiner of dental anxiety. It has been previously suggested that guardian educational level may be involved with a child's dental anxiety. 32 However, this was not observed in the present results. It is important to consider that other factors, such as culture or parental anxiety, may have influenced this result. 22 Another socioeconomic aspect that was analyzed was the type of school the child attended. No significant difference was observed between the occurrence of anxiety in participants from public or private schools. This is different from the results of previous studies, where participants from public schools displayed higher levels of dental anxiety scores compared to participants from private schools. 15 Regarding the dental data collected, no significant difference in dental anxiety was found between whether a child was attending their first dental appointment or not. This result is different from a previous study that found a protective effect of previous visits on dental anxiety. 20 Another previous study observed that mean anxiety scores were higher in children who had never gone to the dentist. 33 These results could be explained by the fact that a lack of previous experience can generate incorrect thoughts regarding dental procedures. 15 Therefore, previous experience can help to deconstruct a negative expectation that may generate dental anxiety. Three previous studies 15,20,33 reported similar results regarding previous experience and anxiety, despite using different age groups and methods. However, those results are different from the results of the present study. This divergence can be explained by the sample used in the present study, with the majority of children having previous dental experience. This may be due to the fact that the study was conducted in a dental care setting, where children receive dental care. One of the common limitations of questionnaire studies is recall bias. 15 There is a possibility that the guardians may not have accurately recalled which previous treatments the child had received. Therefore, the inclusion of this question is a limitation of the research. However, as there were participants who received treatment in other dental offices, where access to dental history was not possible, this question was included in order to standardize the data. Even though it is has been reported in the literature that invasive treatments, such as extraction, may influence dental anxiety, 14 this was not observed in the present study or in the study by Alshohain et al. 15 Furthermore, despite it being widely reported among patients that the high-speed dental handpiece is a cause of dental anxiety, this scores relating to this item were not significant. Moreover, the filling itself was not associated with anxiety, nor where prophylaxis or fluorine. This may be explained by the variation in the degree of invasiveness between different restorative techniques and the atraumatic restorative methods used. 15 Endodontic treatment had an effect on dental anxiety levels. A higher prevalence of dental anxiety was observed in patients who had not received endodontic treatment. Although this relationship was significant, it needs to be interpreted with caution. The performance of minimally invasive dentistry procedures has increased, which minimizes the chance of pulp exposure. Thus, there is a lower demand for invasive procedures, such as endodontic treatment. This is reflected in the small proportion of patients in the sample who had received such treatment. Despite this, these results corroborate those of a previous study, which encouraged endodontic treatment when necessary as it was not found to be associated with greater negative behavior or anxiety. 34 The present study found that anxiety scores were directly proportional to the severity of caries experience, 17,21 suggesting a relationship between them. 5 Although the literature is inconclusive in trying to justify this relationship, it has been suggested that there may be a connection between oral health behavior, such as cariogenic diet and poor hygiene habits, with the attitudes of anxious children, such as avoiding dental treatment. 17 This connection is thought to be a possible explanation for the more severe caries experiences reported by anxious children. 17 However, as only the presence or absence of a caries experience was evaluated, not the severity, this may have influenced the results of the present study, where no positive association between caries experience and dental anxiety levels was found. Based on dmft evaluation, teeth that had already undergone caries treatment were considered to have caries experience, not just teeth that were still cavitated. Although the results of this study found no influence of previous treatments on levels of anxiety, previous literature reports that a child has less anxiety when they have already had a dental experience. 19 This is thought to be because they know the context of the experience, eliminating negative thoughts about dentistry. 19 This may have contributed to the lack of correlation between caries experience and anxiety since some of the patients included as having caries experience had already undergone treatment. Therefore, future studies may want to consider decayed, non-treated teeth. Different results can be found in studies of this kind due to the design, methods of sampling, questionnaire applications, setting, and cultural and socioeconomic variations. 27 As Brazil is a country with a wide range of territoriality, and large sociocultural variations can be found. Thus, the data found in this research should not be generalized. However, it may serve as encouragement for other studies. Since dental anxiety is multifactorial and causes many behavioral problems in children, it needs to be thoroughly studied to optimize pediatric dental care. --- Conclusion Regarding the dental anxiety profile of the sample, no difference was found in the prevalence of dental anxiety between boys and girls. However, younger children presented higher levels of dental anxiety. Particular socioeconomic factors and dental data exerted some effects on dental anxiety. Children from low-income families and those who had not been subjected to endodontic treatment presented higher rates of dental anxiety.

This study aimed to characterize the profile of dental anxiety in pediatric patients, identifying the effect exerted by socioeconomic factors using dental data. A cross-sectional study design with a sample of 120 children aged 7-12 years old was used. Data relating to anxiety levels prior to dental care, socioeconomic aspects (family income, education level, child's school type), and child's dental history (previous dental appointments, previous treatment, caries experience) were collected. Additionally, participants completed the Brazilian version of the Children's Fear Survey Schedule-Dental Subscale (B-CFSS-DS) to assess dental anxiety. Descriptive analyses, chi-squared (X 2 ) tests, and Mann-Whitney U tests were performed, with a significance level of 5%. A total of 51 boys (42.5%) and 69 girls (57.5%) were included. There was no significant difference in dental anxiety between them. However, younger children had higher mean B-CFSS-DS scores (p = 0.036, Mann-Whitney). A higher prevalence of dental anxiety was found in participants from low-income families (p = 0.012, X 2 ) and in patients who did not receive endodontic treatment (p=0.034, X 2 ). Higher mean B-CFSS-DS scores were also observed in participants who did not receive endodontic treatment (p=0.001, Mann-Whitney) compared with those that did receive endodontic treatment. No relationship was found between education level, patient school type, first dental appointment, caries experience, and dental anxiety data. Younger children presented a profile of greater dental anxiety. Socioeconomic factors and dental data exerted some effect on dental anxiety, where children from low-income families and those not subjected to endodontic treatment displayed higher rates of dental anxiety.

INTRODUCTION Combined oral contraceptives: epidemiology and health consequences The contraceptive pill is among the most commonly used contraceptive in Europe today; on average, 19.1% of women of reproductive age use the pill. The prevalence of contraceptive pill usage is reportedly the highest in Northern and Western Europe and lowest in Eastern and Southern Europe . 1 Since their launch in 1960, 2 a total of three new generations of combined oral contraceptives have been approved, which differ in their composition of artificial estrogens and progesterones . 3 According to Khialani et al, 4 COCs that contain the progestins levonorgestrel, norethisterone or norgestimate were the most prescribed COCs in Denmark, the Netherlands and the UK. In Germany, 4th generation COCs containing the progestin dienogestare are currently the most prescribed COCs. 5 --- STRENGTHS AND LIMITATIONS OF THIS STUDY ⇒ This study will allow a detailed exploration of the personal experiences of women and will therefore add valuable information to existing clinical/epidemiological research. ⇒ The results of this study may provide an important basis for future inductive research on quantitative health. ⇒ As the study will be conducted in the context of the German healthcare system, the investigation of the quality of care will be limited. ⇒ Due to the small sample size, the data may not be generalisable. --- Open access The pill was one of the first drugs to be taken up by healthy biological women and can have intentional and unintentional effects. 6 The main desired effect is the prevention of pregnancy caused by a constant intake of artificial hormones. 5 Unintentional effects differ between generations of COCs. 7 Positive unintended effects can include the treatment of hyperandrogenism, 8 dysmenorrhea 9 and premenstrual syndrome. 8 10-12 Unintended negative effects can be both physiological and psychological. Negative physiological side effects found to be associated with COCs include increased stress hormone profiles 13 and risk of venous thrombosis. 14 15 The intake of 3rd generation COCs was associated with an increased risk of thrombosis of 1.5-2 times more than that of 2nd generation COCs. This figure represents an incidence of 9-12 embolisms per 10 000-person years of treatment. 16 Additionally, the negative psychological effects associated with COC use can increase the risk of depression, suicide attempts and completed suicide. 17 18 Critical, feminist views on COCs 'My body is my own'-since their introduction, COCs and their possible effects have been part of feministic debates. [19][20][21][22][23] On one hand, COCs support the medicalisation of the female body and the suppression of natural femininity. However, they also challenge gender norms by empowering women to choose when and if they want to become biological parents. 6 19 20 24 When the first contraceptive pill was introduced to the market nearly 60 years ago, women had 'limited reproductive autonomy'. 25 In our post-feminist society, 25 the pill is no longer only used as a contraceptive. It is marketed to consumers as a lifestyle drug that has desirable contraceptive and noncontraceptive effects. 26 Of course, there are still currently many countries where reproductive autonomy and ready availability of modern contraceptive methods have not yet been achieved. [27][28][29] Recent scientific findings on the possible side effects 13 17 of COCs have led to increasing criticism of their use. 7 24 30 This is evident in the scientific literature, which argues that immediate side effects , [31][32][33] or fear of possible side effects and possible health consequences are among the main reasons women give for discontinuing, or choosing not to use, hormonal contraceptive use. 31 34-37 The discontinuation-the state of art and required research Scientific studies addressing this issue have mainly focused on the return of menstruation [38][39][40][41] and fertility 39 41 42 or collecting the reasons for discontinuation. 43 However, Inoue et al 43 argued that clinical and epidemiological studies do not describe the personal reasons women discontinue contraceptive use. With the growing number of women who stop COCs for reasons other than pregnancy, 31 34 35 44 a new demand for consultation on related health issues might exist. Research also shows that women want more autonomy with regard to contraceptive choices. [45][46][47][48] Therefore, a healthcare supply gap could arise. Health issues, which might appear after discontinuation of COCs, have recently been described by Brighton as the Post-Birth-Control-Syndrome; 'a constellation of symptoms women experience, when they discontinue hormonal birth control'. 49 To the best of our knowledge, no scientific studies have observed the nature and frequency of the non-fertility-related symptoms experienced after discontinuation of COCs. Furthermore, there is a paucity of scientific information regarding health service research about women who stop taking COCs, including the possible resulting healthcare gaps for universal healthcare systems, in countries such as in Germany. Inoue et al 43 pointed out the need for women to articulate their personal views and reasons for cessation of contraceptive use in their own words. Owing to the lack of evidence, this qualitative research aims to inductively explore possible health issues and advantages following the discontinuation of COCs, as described above. Exploration will allow the definition of hypotheses which could form the basis for future research designs. The results also represent an important contribution to health service research for women in Germany and other universal high-quality healthcare systems. --- Study objectives The primary objectives of this study are to first explore the physical and psychological changes women in Germany observe after discontinuing COCs. Second, to explore the supply situation for affected women within the German healthcare system. The secondary objectives are as follows: 1. To understand the practice of discontinuation with regard to COCs and the underlying motives. 2. Identify knowledge bases about potential health consequences after discontinuation of COCs and explanatory influencing factors. --- METHODS AND ANALYSIS Study design This sequential multiperspectival qualitative research project aims to explore the objectives of the study. A mix of qualitative data collection methods and analyses will be used. First, data will be collected through structured episodic interviews with women who have ceased COC use. 50 Second, expert interviews with health professionals will provide a different perspective on the research problem. 51 Key issues and points will be captured in both interview forms. This allows the perspectives and views of the women concerned and health professionals to be contrasted. --- Patient and public involvement No patients were involved in the design of this study. --- Open access --- Sample and recruitment procedures Participants In general, interviewees should be willing and motivated to participate in the interview process. --- Episodic interviews Persons of interest for the first qualitative study are women of reproductive age in Germany who discontinue COCs. Interviews will be conducted with people who meet the study inclusion criteria: reproductive cis-gender women, aged 18-44 years, who live in Germany, have statutory or private insurance status in Germany and have stopped taking the pill in a period of at least 3, and at most 12, months prior to the start of the interviews. Non-cis-gender women assigned as females at birth will be excluded from this study because they may be taking other hormonal medications. Pregnant women will be eligible for inclusion if there was a period of at least 6 months between discontinuation of COCs and pregnancy. --- Expert interviews This data collection will include: health professionals who manage women who have stopped COCs within the German healthcare system; and persons who have dealt with the healthcare situation of women who have stopped COCs and focus on women's health. The definition of an expert may evolve further through the research process and based on episodic interviews. Individuals who do not correspond to this professional profile will be excluded. --- Sample size To investigate the sample size for both qualitative studies, theoretical sampling will be used. 50 52 Thus, the exact number of participants will be determined based on data saturation. The minimum sample size component of the study will be 10 interviews. Data saturation will be reached if, after three additional interviews, no new phenomena or cases emerge. In accordance with Francis et al, 53 the stopping criterion will be tested after each subsequent interview . --- Sampling and recruitment procedure The research project will be conducted from January 2023 to November 2024. --- Episodic interviews Purposive/purposeful, quota and snowball sampling will be used to ensure the diversity of the sample in terms of intersectionality . 52 This also ensures contrast between the interviewees, as well as the generalisability of the study. Recruitment will be carried out mainly through social media and according to the snowball principle. --- Expert interviews Again, purposive/purposeful, quota and snowball sampling 52 selection of cases will be used. Experts should reflect the diversity of women's healthcare, including healthcare groups such as gynaecologists, dermatologists and alternative practitioners. Precise information on the targeted experts will be based on the information received from the episodic interviews. For the recruitment of experts, recommendations from the episodic interviews , as well as the scanning of media and the exploration of organisations with a focus on women's health in Germany will be considered. --- Data collection Data will be collected using two qualitative methods applied sequentially: episodic interviews and expert interviews. --- Episodic interviews Guided episodic interviews with affected persons will be used as the first data collection method for the investigation of the research problem. The interview form was chosen because it allows both narration of the interviewee and targeted questions from the interviewer. In addition, the episodic interview form focuses on experiences that are appropriate for the research topic. Moreover, the episodic interview itself includes a combination of methods and therefore allows triangulation. 50 Interviews will be conducted face-to-face or via a video conference tool at the participant's convenience and under consideration of the current developments in the SARS-CoV-2 pandemic. An interview guide will cover topics regarding the use, discontinuation and personal healthcare experiences of women when they cease COC therapy . Additional probes will be developed by considering the existing literature and a commonly used health behaviour model. An interview protocol will examine the demographic information and specific questions about the history of COC intake of the interviewees. The interviews should last for approximately 30-60 min; However, this is likely to vary greatly depending on the personal experiences of the interviewee. Before data collection, the interview guide will be tested with a minimum of two individuals. --- Expert interviews According to Meuser and Nagel, 51 expert interviews are used to provide a complementary perspective in a research field. This is intended to achieve broader understanding and greater depth. The contextual and operational knowledge experts may provide is relevant. 51 on February 18, 2024 by guest. Protected by copyright. --- Open access Because the specific questions of the interview guide will be based on the evaluation of the episodic interviews, only the preliminary thematic complexes for the interview have been devised: ► The pill as a contraceptive. ► Taking the pill. ► Discontinuing the pill. ► The supply situation for contraceptives in general. ► Final questions. Further, additional probes will be developed by considering the existing literature and a commonly used health behaviour model. Moreover, expert interviews should provide a contrast to the perceptions of women themselves. As in the episodic interviews, expert interviews will be conducted face-to-face or via a video conference tool at the participant's convenience and under consideration of the current developments in the SARS-CoV-2 pandemic. Before data collection, the interview guide will be tested with a minimum of two individuals. --- Data analysis All interviews will be audio-recorded and transcribed verbatim. Data management and analysis will be performed using MAXQDA software. For quality assurance and the presentation of results, the standards for reporting qualitative research will be considered. 56 A research associate will code and analyse the collected material. To ensure intersubjective comprehensibility, approximately 25% of the material for both episodic and expert interviews will be coded by another member of the research team. The codes will be compared and discussed until consensus is reached. The kappa coefficient will be reported to increase rigour. In addition, the work will be presented in qualitative research groups at the Institute for Medical Sociology at the Martin-Luther University Halle-Wittenberg and the Medical Sociology and Rehabilitation Science at the Centre for Human and Health Sciences of Charité University Berlin. There will be a continuous exchange with the head of the project and professors and . The analysis of the episodic interviews will be performed following the process devised by Schmidt. 57 First, categories will be developed based on the transcribed material. For this, open coding will be applied. To guide this process, the research questions and the structure of the guide will be used. This will include a coding scheme with definitions and examples for each code. Subsequently, the interview material will be coded. After coding, the material will be quantified in overview. This shows which cases are particularly typical or deviating in the overall picture. Based on these results, an in-depth case interpretation will be performed.Which should exhaust the abundance of material while providing an exhaustive description of the sample. 57 For the expert interviews, the evaluation method defined by Meuser and Nagel, which was developed specifically for expert interviews, will be applied. 51 The data analysis will be based on thematically related passages. Coding is to be carried out deductively and inductively. A category system will be developed from the interview guide, thus dividing the material into thematic sections. Subsequently, new categories were inductively added. The coding will be based on theory and on current literature. --- ETHICS AND DISSEMINATION Ethics approval statement Ethical approval has been granted by the Ethical Review Committee of the Medical Faculty at Martin Luther University Halle-Wittenberg . Recommendations made by the committee for the study have been implemented. The committee did not express any ethical concerns. --- Theme Sample question The first contact with the pill Can you perhaps remember your first points of contact with the pill? The reasons for taking the pill When you think back: please describe your motivation for taking the contraceptive pill. --- The time during pill-taking Describe the time when you were taking the pill. Can you remember an event that describes it particularly well? Reasons for stopping the pill Could you please describe your personal motivation for stopping the pill? Can you perhaps tell me about a situation that describes this particularly well? The period of discontinuation of the pill Please describe your experience after you stopped taking the pill. Can you describe a specific situation that characterises it particularly well? Current contraceptive method Please describe your current contraceptive situation. The --- Open access --- Ethics This research project will be conducted in accordance with the principles of the Declaration of Helsinki and good scientific practice. Participants will receive all relevant study information before the interviews are conducted. Informed consent will be obtained from all the interview participants for the study. In addition, information regarding data management will be provided. A written declaration of consent, which follows the data protection requirements of the General Data Protection Regulation, will be provided before the interview. Participation can be discontinued at any time without giving reasons. If this occurs, the data already collected will be irrevocably deleted. Withdrawal has no consequences for the participants. Procedures will be implemented to minimise potential harm. Interview data will be stored separately from personal data throughout the research project. All participant information will be removed from the interview data by assigning pseudonyms to the identifying data. Personal data will be stored on a password-protected data stick provided for this purpose. This will be stored in a locked cabinet in a room with double-locking authorisation at the university. These procedures will secure the participants' privacy and confidentiality. --- Dissemination The results of the studies will be published in peerreviewed academic journals. For this study, an Instagram account will be created . Using this Instagram account, published study results and updates will be disseminated. The results will be presented at national and international conferences. --- SIGNIFICANCE AND IMPACT OF THE STUDY This study can provide valuable insights and information about the healthcare needs of women taking and ceasing to take COCs. The qualitative nature of the study has the advantage that it focuses on the personal reasons and experiences of those affected, and contrasts these with the views of experts. This will be a valuable addition to the existing published biomedical/epidemiological research. Moreover, it provides real-world evidence relevant to health service research with the potential to influence regulatory decision making in health agencies. Finally, this study can contribute to the establishment of a research base on gender health and contraception for future research in Germany and other universal highquality healthcare systems. --- Data availability statement Data sharing not applicable as no datasets generated and/or analysed for this study. This is a qualitative study protocol. No data has been analysed yet. --- Competing interests None declared. Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. Patient consent for publication Not applicable. Provenance and peer review Not commissioned; externally peer reviewed.

To cite: Niemann J, Schenk L, Stadler G, et al. What happens when you stop using the combined contraceptive pill? A qualitative study protocol on consequences and supply needs for women who discontinued the combined contraceptive pill in Germany. BMJ Open 2022;12:e057089.

ambulance diversion. 1,2 From 1990 to 1999, the number of EDs in California decreased 12%, whereas the number of total ED visits increased, from approximately 9.0 million to 10.0 million. During the same time period, visits per 100 population increased from 30.0 to 35.0. 3,4 Nationally, from 1995 to 2005, the annual number of ED visits increased by 20%, from 96.5 million to 115.3 million. During that same time period, the number of EDs decreased from 4,176 to 3,795. Both nationally and in California, the landscape of emergency services is changing toward fewer EDs per capita despite an increase in visits per capita. The annual number of ED visits in the United States rose by 18% between 1994 and 2004, whereas the number of hospitals operating 24-hour EDs decreased by 12% during the same time frame. Fewer EDs with increasing overall volume led to average increases in the number of cases among operating EDs, up by 78% between 1995 and 2003. 5 It is known that ED crowding is most severe in areas with lower household income. 6 One basic component of access to emergency services is the presence of an ED in a particular region, as geographic proximity has been shown to play a significant role in patients' ED use. 7 Previous studies have shown that geographical distance not only affects ED utilization, but also reduces utilization in disadvantaged block group areas. 8 To the best of our knowledge, no previous study has attempted to characterize the availability of EDs according to a region's socioeconomic level. This study characterizes one dimension of the availability of emergency services by comparing the number of available EDs per capita across California according to several markers of low socioeconomic status: income, lack of insurance, and fewer years of education. --- METHODS --- Study Design This study was a retrospective analysis using cross-sectional data. This project received approval from the institutional review board of the University of California, San Francisco. --- Study Setting and Population The data were procured from the American Hospital Association Annual Survey of Hospitals, the AHA System, and Network Profile reports from 2005. We linked these data with the 2005 Area Resource Files from the United States Department of Health and Human Services by Federal Information Processing Standard county codes. FIPS county codes uniquely identify counties and county equivalents in the United States. We used FIPS county codes to delineate socioeconomic areas within the state of California. --- Study Protocol The AHA survey collects more than 700 fields of information on over 6,300 hospitals. Hospitals report data for a complete fiscal year, and the average response rate is 85%. Data are estimated for nonreporting hospitals, and incomplete responses were filled based on their most recent information, computed from statistical models, or derived from data supplied by similar hospitals. This particular study uses the data from hospitals in California only. There were 58 FIPS county codes in 2005 and 211 EDs in our data set. --- Measurements The outcome variable was the number of EDs per 100,000 for FIPS county codes in California. We measured three independent variables of socioeconomic status: median household income, percentage uninsured, and percentage of people of age ≥25 years with less than 9 years of education. Median household income per FIPS code was the primary predictor used to measure the relationship of socioeconomic status to number of EDs per capita. --- Data Analysis The first analysis focused on the univariate relationship between number of EDs per FIPS county code and each location-specific summary of socioeconomic data. Preliminary assessments of this relationship were based on separate Poisson regression models for the dependence of the number of EDs on income, education, and lack of insurance. The association of each of these variables and number of EDs is summarized by the results of a likelihood ratio test. The second analysis used Poisson regression models to evaluate the multivariate relationship between number of EDs and income, education, and lack of insurance. All models adjusted for FIPS code-specific population sizes via inclusion of an offset term, allowing results to be expressed in terms of number of EDs per 100,000 individuals in the population. Models used categorical versions of median household income, percentage uninsured, and percentage of people age ≥25 years with less than 9 years of education. Median household income was divided into categories based on intervals increasing by $10,000. Categories for percentage uninsured and percent of people age ≥25 years with less than 9 years of education were constructed using tertiles of the respective distributions. The first, second, and third tertiles of percentage uninsured represent better insured, moderately insured, and poorly insured populations, respectively. The first, second, and third tertiles of percentage of people age ≥25 years with less than 9 years of education represent better educated, moderately educated, and poorly educated populations, respectively. To allow for the possibility that the effects of these socioeconomic indicators were inter-related, initial models included two-way interactions between income and education as well as income and lack of insurance. The two-way interaction terms between income and education, as well as income and percentage uninsured, were not found to be significant and, therefore, were not included in the final model. All analyses were performed using SAS Version 9.1 . Graphical display of results was based on additional regression models including income as a continuous variable. These models allowed for a nonlinear relationship between income level and number of EDs and had comparable fits to those including income as a categorical factor. --- RESULTS We analyzed all 58 FIPS county codes in California . The median population is 175,352, with a range from 1,190 to 9,937,739 persons. The median number of EDs per capita is 0.7, with a range from 0 to 11. The median household income is $40,521, with a range from $28,072 to $70,854. The median percentage without health insurance is 17.6%, with a range from 9.8% to 32.1%. The median percentage with poor education is 10.1%, with a range from 1.8% to 23.8%. The number of EDs per capita in California was inversely related to the primary predictor of median household income . The estimated relative decrease in the number of EDs associated with each unit increase in income was 0.83 . The likelihood ratio test from the corresponding Poisson regression model was significant for income modeled either as a continuous or as a categorical factor . No significant association was found between the number of EDs and either percentage of uninsured or percentage of individuals with less than 9 years of education . We further examined the relationship of income and percentage uninsured to the number of EDs using a multivariate Poisson regression model, adjusting for median household income and education level. Results indicate that better insured FIPS areas have 1.93 times as many EDs as FIPS areas with a greater number of uninsured . This relationship of areas with more insured residents having a greater number of EDs is constant across tertiles; when adjusted for median household income, moderately insured FIPS areas , for example, have 1.41 times as many EDs as poorly insured FIPS areas . When controlling for insurance, areas with higher income have fewer EDs. For each $10,000 increase in median household income, the rate of EDs decreases by 33% . For the same income level, FIPS areas whose residents are better educated have about twice as many EDs as FIPS areas with a high percentage of less educated people, with a rate ratio of 1.99 . --- DISCUSSION We find, contrary to our original hypothesis, that the number of EDs per capita in California is inversely associated with median household income. A closer look beyond these averages in our multivariate analyses, however, shows that across areas with varying insurance and education, there are clear disparities in availability of EDs. When median household income is held constant, areas with more insured residents have more EDs than those with more uninsured residents, and areas with better-educated residents have more EDs than areas whose residents are less educated. These results suggest that, at least in California, low income is not necessarily associated with decreased availability of emergency care as measured by number of EDs in a FIPS county code region, but that there are relationships between availability of EDs and a combination of the socioeconomic factors of insurance and education. It is possible that, when controlling for income, areas with better educated and more insured populations have more working-class people and have more EDs per capita because their population's ED visits are compensated by insurance. Conversely, it is possible that, when controlling for income, areas with less educated and more uninsured populations have fewer EDs per capita because the EDs in those areas have more financial difficulty remaining open or opening in the first place. Characterizing the availability of EDs as they relate to socioeconomic status is also important in informing the current debate about regionalization of ED services. Studies show that directing patients to facilities with optimal capabilities for any given type of illness or injury can improve outcomes and reduce costs. By assessing the availability of emergency services and the capabilities of these services, services can be better organized to provide optimal care based on the patient's location and condition. 9 Our findings substantiate concerns of some practitioners and policy-makers, that emergency services may not be as accessible to populations with lower insurance and education levels, which may relate to varying demand for emergency services based on certain population characteristics. For example, EDs classified as having a high safety-net burden, in terms of serving vulnerable populations, are also shown to have a higher percentage of patients who leave without being seen by a physician. 10 An example of some concerns regarding usage of emergency services by vulnerable populations is demonstrated in the literature. Previous studies have shown that two factors associated with low socioeconomic status, a lack of health insurance coverage and a lack of a regular source of care, were positively associated with two or more ED visits over the course of 3 months. 11 Other data show that Medicaid patients account for the largest percentage of ED visits when compared with uninsured or privately insured patients. Medicaid patients also make up the largest proportion of patients seeking nonemergent care in EDs. 2 Little or no education, another variable associated with low socioeconomic status, has also been associated with routine ED use. 12 These concerns, along with the findings of our study, illustrate the problems that factor into taking socioeconomic status into account when making emergency services available to diverse populations. Despite the evidence that vulnerable populations utilize emergency services more frequently, hospitals are mainly adding capacity in suburban markets with higher household income. 6 While previous studies show that overall ED bed capacity per capita may be increasing, 4 there have been no studies that look at the distribution of this increased bed capacity. We show that the number of EDs in FIPS codes varies by insurance coverage and education across income levels in predictable ways, so that areas whose residents are insured and who are better educated are consistently associated with a greater number of available EDs. Viewed in the context of existing literature, our results suggest that despite an increased number of EDs in low-income areas, a more useful method to determine the need for future emergency services may be according to the percentage of uninsured and less educated residents in a given region, as these factors may influence need more accurately. Uninsured and less educated residents may require increased utilization of emergency services due to factors that cannot be explained by income alone. While we find a significant negative relationship between number of EDs per capita and income, our results show that when insurance and education are considered, there are clear disparities in communities that have more: those with "more" insurance and "more" education also have "more" availability to EDs . --- LIMITATIONS This study was based on cross-sectional data for the year 2005 and therefore is not able to capture recent changes in the dynamic market of health services. It is indeed possible that since 2005, the number of EDs in both low-and high-income FIPS counties has changed, altering our results. Our hypothesis, based on historical data regarding the more marketdriven influences of hospital and ED openings and closures, would suggest that the univariate inverse relationship between EDs and income might, at this point in time, be weaker, which would make our findings conservative. Second, the results could be skewed due to a wide range of population in FIPS county codes in California. Counties with large populations have a wide range of socioeconomic levels, and using the median household income may not be an accurate representation of socioeconomic status. Even though we controlled for population by looking at EDs per capita , outliers with very small and very large populations could skew the correlation results for EDs per capita versus income. Third, while our focus is on the availability of emergency services that can provide a broad range of services, our study does not take into account the presence of minute clinics or urgent care clinics as a potential alternative source of providing care for certain conditions. These facilities could potentially be related to access issues, but we would believe them to be more prevalent in higher income areas, thus making our estimates conservative. Finally, our study does not account for geographical considerations such as proximity to an ED outside of the county. Specifically, people may not necessarily seek emergency care at an ED within their FIPS county code, particularly if an ED outside of their FIPS code is closer or more accessible . The presence of an ED may not be an exact indicator of access. Relationship between income and EDs per 100,000 population. EDs per 100,000 population by income according to percentage with no insurance in FIPS code. FIPS = Federal Information Processing Standard. EDs per 100,000 population by income according to percentage with poor education in FIPS code. FIPS = Federal Information Processing Standard. --- CONCLUSIONS California counties whose residents are poorer have more EDs per 100,000 residents than those with higher median household incomes. However, for the same income level, counties with more insured and more highly educated residents have a greater number of EDs per capita than those with less insured and less educated residents. This study has important policy implications for ED patients as well as the delivery of emergency services in California. These findings shed some light on the phenomenon of overcrowding in low socioeconomic areas-despite a greater number of EDs in poorer areas, other factors may determine availability of services. Even though our chosen measure of number of EDs per population may not be an exact indicator of access and capacity, the combination of such measures can provide additional data to policy-makers. These data suggest that reexamining and possibly reshaping current policy to address the distinctive need for emergency services in areas whose residents are at a low socioeconomic level may be warranted.

Objectives-The study objective was to examine the relationship between number of emergency departments (EDs) per capita in California counties and measures of socioeconomic status, to determine whether individuals living in areas with lower socioeconomic levels have decreased access to emergency care.The authors linked 2005 data from the American Hospital Association (AHA) Annual Survey of Hospitals with the Area Resource Files from the United States Department of Health and Human Services and performed Poisson regression analyses of the association between EDs per capita in individual California counties using the Federal Information Processing Standard (FIPS) county codes and three measures of socioeconomic status: median household income, percentage uninsured, and years of education for individuals over 25 years of age. Multivariate analyses using Poisson regression were also performed to determine if any of these measures of socioeconomic status were independently associated with access to EDs. Results-Median household income is inversely related to the number of EDs per capita (rate ratio = 0.83; 95% confidence interval [CI] = 0.71 to 0.96). Controlling for income in the multivariate analysis demonstrates that there are more EDs per 100,000 population in FIPS codes with more insured residents when compared with areas having less insured residents with the same levels of household income. Similarly, FIPS codes whose residents have more education have more EDs per 100,000 compared with areas with the same income level whose residents have less education. Conclusions-Counties whose residents are poorer have more EDs per 100,000 residents than those with higher median household incomes. However, for the same income level, counties with more insured and more highly educated residents have a greater number of EDs per capita than those with less insured and less educated residents. These findings warrant in-depth studies on disparities in access to care as they relate to socioeconomic status.health policy; access to care; access to emergency services; emergency departments per capita A critical issue nationally in emergency medicine and health policy is the population's access to emergency services. Factors that affect access across all national markets, including urban, suburban, and rural markets, are the rising demand for emergency services, shortages of hospital nurses and on-call specialists, availability of functioning emergency departments (EDs), number of beds, overcrowding, reduced inpatient capacity, and

Introduction One in four adults in the U.S. report living with a disability [1]) and there is little attention paid to the intersectional experience of disability for historically marginalized populations, like Native Americans [2]. Within young adults in the U.S., cognitive disabilities are most prevalent [1], including intellectual and/or developmental disabilities. Intellectual and developmental disabilities are lifelong disabilities diagnosed in childhood that involve the individuals requiring varying levels of support for completing daily activities and can include difficulties with intellectual functioning [3]. Like other minoritized groups, people with disabilities and Native Americans experience lack of access to health care. Women with disabilities are less likely to receive cervical and breast cancer screenings compared to women without disabilities [4,5]. Additionally, Native American women do not receive recommended cancer screenings as often as other minority groups and white women [4,5]. This study is framed by ecosocial theory [6,7], which considers historical and dynamic influences, as well as discrimination, on health and lived experience. For example, people with IDD commonly live in congregate settings or with family caregivers [8], which may affect their adherence to cancer screening guidelines [9]. Furthermore, Arizona, where this study took place, is a primarily rural state and more than a third of the state's Native American population lives in nonmetropolitan counties [10]. Rural-dwelling individuals have more limited access to cancer care and often travel long distances to access it [11,12], averaging health care trips that are nearly a third longer than trips among urban dwellers [13]. While many Native American people reside in rural tribal lands, approximately 60% of people who identify as Native American live in urban areas [14]. Both rural and urban Native American populations report using traditional healing in addition to allopathic medical care [15,16], and a number of international bodies have acknowledged the importance of indigenous healing practices in Native American people's lives and well-being [17]. Furthermore, despite the fact that Native Americans have a legal right to federal health care services, there may be limited access to specialty care, such as cancer care, in these systems [18]. Accordingly, this project sought to address cancer screening among Native American women IDD, a group of women who experience disparities in access to health resources. We began with an existing breast and cervical cancer screening education program for people with IDD called Women Be Healthy2 [19]. WBH2 has been shown to increase knowledge regarding cervical and breast cancer screenings among women with IDD [19]. Led by a community advisory board with members having expertise in cancer care, health care and/or disability resources , the team's community engagement work found a lack of attention to disability in many cancer control programs in Arizona and a need to attend to the urban and rural contexts of Native American women with IDD. The goal of this qualitative study was to collect formative data for adapting the WBH2 program to address the cultural context of Native American women with IDD in Arizona. In conducting in-depth interviews with Native American women with IDD, their caregivers, healthcare and service providers, and community leaders, we asked, "What are the influences on breast and cervical cancer screening for Native American women with IDD?" Given the prevalence of disability among Native Americans in the U.S. [20], the larger implications for this culturally adapted program will be a health education resource developed in accordance with the principles of universal design [21], in which educational resources are accessible for all regardless of cognitive, sensory, or physical functioning differences. In this paper, we report the results of the qualitative data collection using concepts from the ecosocial model and discuss the implementation of these findings using social cognitive theory [22]. The adapted program is titled My Health My Choice. --- Materials & Methods --- Study Design and Study Participants The consolidated criteria for reporting qualitative research was used to guide the reporting of methods and findings [23]. This needs assessment was intended to explore the phenomenon of breast and cervical cancer screenings among Native American women with IDD in Arizona and therefore was guided by a phenomenological approach [24]. The study was overseen by a community advisory board, who assisted with identifying potential community partner agencies to join the university-based team members in efforts to address breast and cervical cancer screening among Native American women with IDD. The community advisory board recommended that we find both a rural based partner and an urban partner to ensure the project considered both contexts related to accessing cancer screening services. We first partnered with one community agency in this needs assessment. Our rural partner is the Hopi Cancer Support Services, a Centers for Disease Control and Prevention funded breast and cervical cancer early detection program serving Native American individuals residing in their catchment area, which is a rural region on tribal land. We did not initially find an urban community partner agency, but began recruiting urban dwelling participants while working with the community advisory board to identify this partner. After collecting some of the data in urban areas of Arizona , the team was able to identify and add an urban partner, the Tucson Indian Center, a provider of health and social services to Native American people in southern Arizona. Study participants were recruited purposively based on meeting the inclusion criteria, which included either being a Native American woman with an IDD, being a caregiver to a Native American woman with an IDD, or being a community leader or provider to Native American women with IDD. Participants were recruited through email, flyers, and face-toface interactions at local IDD and/or Native American focused events. In total, the study team members interviewed 30 rural residing individuals and 18 urban residing individuals. There were no incidences of interviewees dropping out or canceling their interview. Since the intention of the interviews was to collect information to culturally adapt a breast and cervical cancer screening education program for Native American women with IDD, the study team collected the ages of the participants who were Native American women with IDD to determine if they were at ages for which these cancer screenings were recommended. Among the Native American women with IDD, four were urban residing Native American women with IDD (age range 29- --- Study Team, Study Setting and Data Collection The study team was led by three doctoral-trained researchers, two who identify as White females and one who identifies as a Native American female. All three researchers have expertise in community-engaged and qualitative research. Additional team members include undergraduate and graduate students who identified as female and either White, Latinx, or Native American. For some of the rural-residing interviews with women with IDD and their caregivers, a Native American woman from a rural community with experience in research was hired to assist with recruitment and then the completion of the interviews. The study was also overseen by a Community Advisory Board who met quarterly to provide feedback on the design of the study and provided suggestions for study recruitment [25]. The study was approved by the lead university's IRB with a ceded review by the secondary university's IRB. The study was also approved by all required tribally affiliated entities. All interviewees provided informed consent prior to the interview. Informed consent materials were modified using the concepts of universal design to meet the communication skill level of the women with IDD and other participants who may have non-disclosed literacy limitations. The informed consent document used the teach-back method to ensure that study participants understood the benefits and risks of participating in the study. For all participants, the informed consent process was guided by the Getting Involved in Research and Training Projects: A Guide for Persons with Disabilities [26] and used simple language and imagery for individuals with low literacy levels. Consent forms were read to all individuals interested in participating in the study, and opportunities were provided for questions and answers prior to confirming consent. After informed consent was received, semi-structured interviews were completed either in person or over the phone, depending on the person's preferences. In most cases, only the interviewer and the interviewee were present during data collection. In three cases another person was present. This occurred as some of the women with IDD were joined by a support person for the interview . There were several team members who completed interviews, including students, the lead researchers and a hired consultant, who was a Native American woman. Most of the interviewees had no previous relationships with the research team members who conducted the interviews. The interview guides were developed by the research team. Interview guides were developed that were unique to each group including Native American women with IDD, caregivers and providers/community members. The interview guides included questions with prompts for probing regarding experiences with health care broadly, barriers and facilitators to breast and cervical cancer screenings, and preferences for learning about breast and cervical cancer screenings. Imagery was available regarding breast cancer screenings and cervical cancer screenings to assist with facilitating discussion. Materials were sent in advance to individuals who participated in phone interviews. Interviews lasted between 30 min and 1.5 h. --- Data Analysis Each interview was audio recorded and transcribed verbatim for analysis. Two Native American graduate students were the two coders for data analysis. An a priori codebook was initially established based on the topics discussed in the interview guides. The two coders then used a constant comparative method to review coding and update the code book as needed with codes and corresponding themes . The two coders provided regular updates regarding initial findings to the principal investigators for discussion and consensus on updates to the codebook. The team determined that we had reached saturation when no new codes were added to the codebook. All data were managed using NVivo qualitative software [27]. --- Results Guided by the ecosocial model, our results indicate individual, interpersonal and community/institutional influences on cancer screenings for Native American women with IDD. Many of these influences are relevant to both the urban and rural contexts, but we have noted below whether the concerns were more relevant in one context than the other. The results reported below are interviewees' perspectives on cancer screening for themselves, their family members, the women with disabilities with whom they work, and/or the population of Native American women with disabilities. --- Individual Influences on Cancer Screening Providers, caregivers and women with IDD themselves described the following individual influences on cancer screenings or health care in general: financial concerns; individual attitudes about health care; fears about cancer or cancer screening; need for information about screening; general lack of health education; and beliefs about screening. --- Financial Concerns Financial concerns were part of the barriers to care that were highlighted among providers and caregivers. For many of the interviewees, financial burdens that come with caring for loved ones with IDD were a common barrier that resulted in individuals overlooking their health. For example, one provider commented that a young person with a disability with whom they work did not have health insurance until recently; hence, nonurgent health concerns were addressed outside of the health care system. The provider noted, "[The person's] mom hasn't had insurance; she doesn't have money for that." Once the family was able to get insurance, they visited every health care provider for checkups. --- Attitudes about Health and Health Care The behaviors, perceptions and assumptions about cancer screening can influence women's willingness to get screened. Interviewees described the challenges of decisionmaking among women with IDD who might not want to have a cancer screening. Urban Provider #2 noted that a woman she supports "would really struggle" in going for a cancer screening because of the risk that she might be diagnosed with cancer. The provider commented that another medical issue nearly forced the woman with IDD to move into a group home, saying: "I could see her resisting anything that could definitely head in that direction." Providers recognized the hesitancy of the women with IDD to receive screenings and to attend appointments may be the result of a history of trauma. An urban provider described trying to have conversations with women with IDD about having gynecological exams and referenced the high rate of abuse among people with IDD [28]: "They don't feel comfortable talking about . . . did they go to the OB/GYN and that kind of stuff . . . I ask the support coordinator . . . "What are the barriers?" And she said that it's . . . pretty much, that because of . . . a lot of high incidence of sexual abuse." Hesitancy to get screened may also stem from encountering discrimination or bias in health care settings. One woman with IDD described her frustration with how her health care provider treats her: "She's more concerned with my disability than anything." Providers also described feeling as if women with IDD do not get screened because they are in denial about being at risk for cancer. A rural provider noted: "But, like some of them are in denial stage . . . and in the long run, I see people that are being diagnosed . . . and all I have to say is, I wish they would just keep their appointment and get themselves checked and, you know, things will not happen to them." --- Fears about Cancer or Cancer Screening A rural caregiver of a woman with IDD shared a perspective that reflected fear about cancer, but also a belief that individuals should know more about cancer: "You just got to know more about the cancer and, you know, how you can help, because the way I look it, cancer just takes your life. I mean, you know, there's no turning back. You just got to live day-to-day with it...." A rural provider highlighted negative feelings and fear regarding cancer screenings among women with disabilities. This provider also emphasized the challenge of ensuring their patients are comprehending what will be completed during the appointment: "A lot of them with disabilities, they haven't probably had a women's exam for a long time, and the ones that we did do, you know, they didn't like it . . . because of its being painful, and they're not sexually active, so . . . I think, for them very scary and frightening and uncomfortable . . . so there's got to be a way to try to make them understand what's going to happen to them." --- Need for Information about Cancer Screening A rural woman with IDD described the need for information regarding cancer screenings as a beneficial approach to staying updated on her overall health. It was stated that due to their previous diagnosis of cervical cancer, they feel compelled to be informed on all the basic education on cancer screenings: "Well, I guess it doesn't hurt to refresh, you know, your education on cancer screening. It's been a couple of years since I had cervical cancer . . . So, I just need basic education." An urban woman with IDD and her caregiver described wanting more information about cancer screening. They noted that informative videos or media are hard to access due to limited internet accessibility in the group home: "We don't really have internet here or computers to use, so even videos are a little difficult to come by... sometimes they have programs where you can go online and look at things and there's videos and descriptions, but we don't really have access to that." --- General Lack of Health Education for Women with IDD An urban provider described the general lack of health education for women with IDD. The provider argued that the lack of formal and informal education has led individuals with IDD to believe the health topics do not pertain to them. "They may not have either the formal education about these things, or the informal education...And then sometimes they're not included in sex education, the formal sex education that happens in schools... So, then, and you put yourself in the setting of you're now a 50-year-old woman, and you may not have built up like a whole series of informal places that you get information...There's a whole network of informal ways that people learn... and this goes across the board with a lot of health messaging, less accessible to people with disabilities, or they don't see it as pertaining to them because it's never targeted. You never see a woman in a wheelchair, for example, on a get your mammogram billboard. Right?" --- Beliefs about Cancer Screening One woman with IDD highlighted her concern with regard to her family history with cancer, describing her interactions with the community health educators, and sharing her belief that it is important to get screened: "I had family members that passed away with cancer, and so the educators tell you, you know, it's best to take a test . . . for early detection before it's, you know, too late. Well, I like, you know, getting screened, because you never know, like you said, that out of so many that in your lifetime that you could possibly be prone to cancer, especially if it's in your family history." --- Interpersonal Influences on Cancer Screening Participants described the following interpersonal influences on cancer screenings or health care in general: provider and caregiver bias, the importance of communication, family and caregiver relationships, and relationship with the health care provider. --- Provider & Caregiver Bias Urban and rural health providers shared their feelings that provider bias may cause a barrier to screening for individuals with IDD. It was described that health providers or facilities fail to provide adequate care and attention to patients with IDD. This act often leaves patients with the feeling of being dismissed, insignificant, and overlooked. A rural provider noted: "...sometimes I feel like in certain situations, some facilities just think that because they're not capable of understanding these things, they don't take the time to explain it to them, so they automatically write them off as they don't need it or they waive their right..." Furthermore, an urban provider highlighted how health care providers tend to see the disability status first rather than the individual. The patient's conditions or diagnoses become the focus of a patient, which limits the healthcare they receive, such as necessary preventive screening, services, and patient care. "For people with disabilities in general, they tend not to get asked about healthcare screening and [are] more likely to be asked about stress and stuff like that. So, women particularly with disability are often assumed not to be sexually active, they never get a sexual history taken. It's called diagnostic overshadowing . . . where that primary diagnosis is all the physician can see." Support professionals commented that health care providers may not provide screenings for women with IDD due to misperceptions about risk: "Doctors often don't think that it's important to do any type of cervical checks on females with a development disability. And I've heard medical professionals anecdotally state, "Well . . . they're not sexually active, so we don't have to worry about it . . . So, I think our biggest barrier, and when it comes to cervical screening, is the doctors." Rural and urban providers commented that caregivers perpetuate these ideas about risk, thus creating barriers for tests, like cervical cancer screenings, that may also look for a commonly sexually transmitted infection , which can cause cervical cancer. A rural provider argued: "The caretakers might . . . feel that they don't need to go to these appointments because they are not sexually active." --- Importance of Communication Providers and caregivers, in particular, highlighted the importance of communication in the health care interaction. Participants mentioned that individuals with IDD may not be able to express or communicate what they are feeling or experiencing. This requires the health care provider to effectively communicate with the patient. One urban provider described her experience: "... if they're having any health issues, it's very difficult to figure out what the problem is, because either they cannot communicate . . . .or they have some kind of speech impairment, or they just don't know how to express...what's happening with them." A rural care provider highlighted that individuals with a disability may feel afraid to express what they may be going through, instead keeping it to themselves: "They're afraid to talk about it. They might have other issues, you know, going on in their mind, but they don't want to really tell anybody about what's going on with them." Providers and health educators described utilizing various communication methods such as visual communication with pictures and diagrams to help women with IDD understand the process of screening. A rural health care provider described getting patients ready for screening: "I usually draw out the photo...some of the girls, too, that come in for their first Pap smear, they're already very nervous about it, so I always tell them, you know, I will draw it out, I explain what I'm doing before we do it, and then I literally like walk them through the entire exam, so they what I'm doing, they feel more comfortable about it." For an urban health care provider, patient-centered care was provided in how they communicated with their patient such as taking the time to explain in-depth the screening process and giving the patient time to feel comfortable with the screening. "I don't go straight to the Pap smear first thing. I may just the first time say, "I just need to look at your whole body so I'm going to sit here and have your legs go, you know, in the stirrups and I'm just going to not touch and look." Right? Okay, six months later, I might look and then say, "Okay, now this time I'm going to touch the outside part to make sure there are no lumps and bumps," right? And then eventually you can get to the point where sometimes you can do a Pap smear. There are patients I take care of that do not have the capacity to give consent or to understand what I'm trying to do. There are a few who, you know, their parents want them to have it. I think it's important for them to have it. Women with disabilities are some of the highest risk for unwanted sexual assault. And so you can't assume, you know, that somebody hasn't been exposed to HPV even if it wouldn't seem as if they would have had an opportunity to be exposed." Caregivers discussed the need for cues to notify health professionals of whether a patient is non-verbal. In an interview with an urban woman with IDD and her paid caregiver, they advocated for using special tools: "Even just the, "I communicate using" [sign] because we have some clients who are non-verbal and that would be great. Because there have been circumstances where the doctor will turn and talk to the client, but they just can't communicate." --- Family and Caregiver Relationships Family and caregiver support can be essential to health care access, including screening. Caregivers are often tasked with several responsibilities such as providing transportation, interpreting, or providing general care for the woman with IDD in health care interactions. "I have to take her in, escort her, be there with her so that the doctor can explain some things to her which I would go over, you know, tell her in [named language] what was said . . . to just be there with her and translate whatever it is that the doctor is getting across to her. That's including her meds or why she can't do this or why she can't do that . . . not from me but from her doctor." --- Relationship with Health Care Professionals Women with IDD shared their thoughts about their health care providers. A rural woman with IDD commented, "I like my doctor. She's always concerned about my disability. She's . . . more one of the caring ones. It's not where you just go in, and she does this, and so, "Okay, see you in six months." An urban woman with IDD highlighted the good communication she has with her doctor, "I'm able to talk with my doctor. I'm able to explain to my doctors what's wrong with me." . Women with IDD and caregivers acknowledged feeling more comfortable with femaleidentifying health care providers for cervical cancer screening. When she was asked about her last Pap test , the same woman quoted above said that she initially had a male doctor and "...I got a little nervous. I wanted a female, but they didn't put me with a female . . . . but I had two different doctors . . . the only one that did a Pap smear was a female doctor." A health care provider stated that they take extra steps to make their patient comfortable, respecting patient concerns and often getting on the same level as their patient: "I really try to meet them where they're at and not push them out of their comfort zone...[laughs]... like we'll get them onto the exam table. Sometimes it's hard-I've had a couple patients where they don't want me to elevate the table up or they get really dizzy or anxious with that, so I have to leave the table basically pretty low to the ground, and then we still try to put their feet in the foot rests, but I kind of have to crouch on the ground sometimes, because I can't raise the table up" --- Community or Institutional Influences on Cancer Screening Participants described the following community or institutional influences on cancer screening: distrust of allopathic medicine, preference for traditional medicine, traditional ways of knowing, limitations to receiving community services, and accessibility of health care facilities. --- Distrust of Allopathic Medicine Distrust of the health professional, facility, or screening process was highlighted as a prevalent barrier for women with IDD to obtain cancer screening. Participants shared experiences with trauma, which further limits their trust in the care that may be offered to them, as expressed by an urban provider in describing a woman with whom she works. "For her, the other thing is trauma, so she won't get those procedures done, because she's had the trauma sexually and physically . . . so to her it just relates to being victimized and, you know, you can't justify, you know, the good behind the exam." Additionally, when providers believe that individuals with IDD do not need cancer screenings, it further prevents these individuals from seeking or obtaining preventive care. An urban provider expressed the need for self-advocacy, acknowledging: "... most providers don't see that [screening is] necessary. And they [person with an IDD] can push [the health care provider], but it takes somebody to have the confidence and the know-how to push back and say, "Oh, no, you're going to do this screening. You're going to do this test." --- Preference for Traditional Medicine and Ways of Knowing Participants referred to the need to acknowledge women's relationships with their families and their cultural context. Several rural providers described how they address women and families' preference for traditional medicine and ways of knowing. They highlighted the need to emphasize that getting cancer does not mean that "Something bad happened or somebody did something bad and now their family's paying for it, those kind of things." They highlighted their identity as Native American and their respect of cultural knowledge to engender trust with clients. One rural provider commented that clients are, "comfortable in who we are, I guess, 'cause we're from their village...and we can speak and understand their language, you know, and we're, we're aware of our surroundings and our culture and our Native, I guess, the Native things that we do culturally." Another rural provider described the strategies they use to encourage women to get cancer screenings: "And women are the main factor in this matrilineal society even though it's a patrilineal, you know, governing system, it's the women that are making the decisions. It's the women that are, you know, the ones that, you know, do the tending to the children, have the children. You know, they're the life givers . . . .So, if you-I notice that even here they use objects to identify with cancer like corn. 'Okay, here's a healthy corn. Here's a corn that didn't form very well and started rotting, and you know, this is what cancer can look like.' So, they kind of, you know, weave together the good and the bad with what they're familiar with in their environment." --- Limitations to Receiving Community Services Participants described a general lack of services, with urban and rural providers, caregivers, and women highlighting lack of transportation as a major issue. For women residing in a rural area, transportation to appointments is difficult because of bad road conditions, long distances, and the lengthy time commitment to drive to appointments. A rural woman with IDD commented: "Sometimes with specialty clinics you have to go way out far like to wherever they're held at . . . . the only thing that's, you know, time consuming . . . is when . . . you have to travel far to get to your appointment." A provider in a rural setting illustrated the distance needed to travel to appointments, saying: "We're such a rural area here that, you know, if you're at this point right here, you have a choice of going 30 min this way or an hour that way." For urban areas, there can be access to buses and transportation services like Uber and Lyft, but cost and accessibility are factors. One urban provider's perspective highlighted the burden of cost and how it can determine if patients will attend an appointment, noting that it is a decision between "putting your money towards gas for a long trip in your truck or toward groceries that week." Furthermore, when health care facilities have limited resources or patients experience long wait times, it may dissuade women with IDD from returning for cancer screening. A rural woman with IDD commented, "One time we had to, we were there [at the clinic] most all day just to get medication. Kind of a long wait. Or that you have to go back the next day to pick it up." One rural caregiver highlighted legal concerns related to supporting a woman with IDD" pointing to the difficulty of having caregiving responsibilities without the necessary power to carry out those responsibilities. Without the power of attorney, there can be limitations in what the health care provider can do for the patient. The caregiver stated: "We're not actual power of attorney of her financial or her medical, so we've been just doing the best we can as far as taking her to her appointments, receiving her medicine. But now because [she is on] different kinds of medicines, they're asking for someone that's legally medical, I guess, for her to sign these papers . . . we're finding a lot of red tape right now." --- Accessibility of Health Care Facilities Health care facility accessibility is imperative to mobility for women with IDD and for caregivers who assist their patient or loved one with IDD. A rural caregiver discussed their frustration when there was limited to no proper facility accessibility: "There's no easy way to get a screening due to her disability. In some areas it might be a closed area or just cluttered some ways to the left, [and] to the right, she's not able to move." Another rural caregiver shared their dissatisfaction with inaccessible clinical spaces which require staff to transfer patients from their wheelchair to the space, commenting, " . . . when they're on electric chairs, you got to get them out, transfer them, and they're even, there's even some members with a Hoyer lift you would have to use to transfer them" . Participants emphasized other methods for increasing accessibility, such as including the use of Indigenous languages to describe aspects of screening and providing interpreters for non-English speakers. A rural provider felt that exam room design could provide distractions to ease the worry or anxiety of the patient, recommending "making one room that's colorful" or "making your rooms more friendly looking, bright." --- Discussion Our findings address the influences on breast and cervical cancer screening for Native American women with IDD. The findings enabled the study team to hear from people who experience disability, their caregivers, and health care providers about how they understand the individual, interpersonal, and community/institutional influences on women's receipt of breast and cervical cancer screenings. Participants described a variety of individual influences on cancer screenings or health care in general, including financial concerns, individual attitudes about health care, fears about cancer or cancer screening, the need for information about screening, the general lack of health education, and beliefs about screening. Participant comments referenced the individual effects of inequity on the experiences of Native Americans and people with disabilities. Among people reporting disabilities, only 11.5% are uninsured in 2019 [28] but 17.7% report being uninsured at some point in the past year. People who identify as Native American are more likely to be uninsured: 32.9% were uninsured in 2019 and 37.6% were uninsured at some point in the past year. Furthermore, people with disabilities are less likely than the general population to graduate from high school. In 2018-2019, only 72% of people with disabilities graduated from high school [29,30]. Additionally, there is a lack of consideration for addressing the health literacy of adults with IDD so they can be engaged in decisions about their health care [31]. Interpersonal influences on cancer screenings or health care in general included: caregiver and provider bias, the importance of communication, family and caregiver relationships, and relationships with health care providers. In this study, participants asserted that caregivers and providers perpetuate biased ideas about women's lack of risk for cervical cancer, in particular. They note that ideas about women with IDD as asexual may present a barrier to cervical cancer screenings. Biases about people with disabilities affect patient care more broadly. Across the United States, only 40.7% of physicians reported confidence in their ability to provide quality care to people with disabilities, and a majority felt that people with disabilities have worse quality of life than the general population [32]. Biases about people with disabilities can significantly affect healthcare interactions, including whether or not people with disabilities receive care. A clear example of how bias influences care was seen during the COVID-19 pandemic, during which health systems' policies deprioritized people with disabilities for life saving medical interventions during instances of medical rationing [33]. Furthermore, as our participants noted, the role of informal or paid caregivers can be important in influencing health care. Other research has noted that strong support systems can influence cancer screening among people with disabilities [34]. In addition to the individual and interpersonal influences on cancer screenings, study participants also highlighted community or institutional influences on cancer screening, including distrust of allopathic medicine, preference for traditional medicine, traditional ways of knowing, limitations to receiving community services, and accessibility of health care facilities. As participants indicated, many Native American communities view allopathic medicine with apprehension due to a long history of trauma, oppression, and maltreatment [35]. Furthermore, high rates of violence and sexual assault for both women with IDD and Native American women [28,36,37] may influence the populations' willingness to get cervical and breast cancer screenings and require providers to engage in trauma-informed care [38]. Providers who work with Native American women shared insights into bridging traditional medicine with allopathic approaches in order to engender trust but also make cancer screening relevant within women's worldviews. --- Conclusions Next Steps: Integrating Findings into the My Health My Choice Program Formative in-depth interviews provided insight into the influences and cultural considerations necessary for adapting the original cancer screening education program, Women Be Healthy 2, for use with Native American women with IDD in urban and rural contexts. Using an essential elements approach [39], which identified the elements presumed to achieve the desired outcomes, we incorporated adaptations from the qualitative results reported here into the adapted program, My Health My Choice. As My Health My Choice is an individual intervention , adaptations focused on cultivating the knowledge and skills in Native women with IDD and their caregivers to successfully advocate for their health and minimize anxi-ety in a health care context that may not consider their unique needs. In acknowledgement of the importance of caregivers in cancer screening adherence, the program is delivered in dyads . The COVID-19 pandemic and public health restrictions on tribal and non-tribal lands led the team to make a major change in program delivery, shifting from in-person discussions to remote delivery by teleconference or telephone. The team will then test the feasibility and acceptability and explore the effectiveness of the adapted cancer screening education program, My Health My Choice, with both urban and rural Native American women and their caregivers. --- Strengths and Limitations This study reports a largely underrepresented group of people in health disparities research, Native American women with IDD. Given this study's methodology, which enabled us to describe variations in multiple populations , the results of this work may not be generalizable to other groups of women with IDD who are also from underrepresented and minoritized groups. However, this work contributes to our understanding of barriers to receiving effective types of health services, in this case cancer screenings. The study also highlights the need to address multi-level issues that Native American women with IDD face when trying to access health resources. It is important to educate Native American women with IDD about cancer screenings, and in doing so, also help them plan for getting the screenings considering the personal resources available to support their health care navigation. --- Data Availability Statement: Due to privacy and ethical concerns, the data cannot be made available. --- Acknowledgments: The authors would like to thank Veronica Boone, MSW, at Tucson Indian Center, and Dana Russell, BBA, Hopi Cancer Support Services for their partnership. The Hopi Tribal Council approved this manuscript in April 2022. --- Author Contributions: Conceptualization: J.S.A., H.J.W. and J.A.B.; Methodology: J.S.A. and H.J.W.; Data Curation: J.S.A., H.J.W., A.B. and J.E.; Formal Analysis: J.S.A., H.J.W., A.B. and J.E.; Writing-Original Draft Preparation: J.S.A., H.J.W., A.B. and J.E.; Writing-Review and Editing: J.S.A., H.J.W., A.B., J.E., A.A., K.R. and J.A.B.; Project Administration: J.S.A. and H.J.W.; Funding Acquisition: J.S.A., H.J.W. and J.A.B.; Supervision: J.S.A., A.A., J.A.B., K.R. and H.J.W. All authors have read and agreed to the published version of the manuscript. Funding: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health under the awards for the Partnership of Native American Cancer Prevention U54CA143924 and U54CA143925 . Armin's work on this manuscript was partly supported by a grant from the Department of Health and Human Services, Administration for Community Living, Administration on Intellectual and Developmental Disabilities-University Affiliated Programs, Grant No. 90DDUC0090-01-00. --- Institutional Review Board Statement: The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of The University of Arizona . Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. --- --- Appendix A. Major Code Tree --- • Barriers to screening

Like other minoritized groups, people with disabilities experience lack of access to health care. People with intellectual and developmental disabilities (IDD), which are lifelong disabilities diagnosed in childhood requiring varying levels of support for completing daily activities, are less likely to receive preventive health care such as cancer screening. Furthermore, Native American women are less likely than White women to receive cancer screenings. In this qualitative research with Native American women with IDD, their caregivers, healthcare and service providers, and community leaders, we asked, "What are the influences on breast and cervical cancer screening for Native American women with IDD?" with the goal of adapting an existing cancer screening education program. Semi-structured in-depth interviews (N = 48) were audio recorded and transcribed verbatim for analysis. Two coders used a constant comparative method to code and revise the a priori codebook with subthemes and new codes. Results highlighted individual, interpersonal, and community/institutional influences on screening, emphasizing the individual effects of social inequity on this population, the importance of ableist bias in recommending cancer screenings, and opportunities to integrate traditional ways of knowing with allopathic medicine. Results of this work were used to adapt a cancer screening education program for Native American women with IDD.

Introduction Around 20-25% of workers in Western cities are engaged in some form of remote work. Over one-fourth of them work from home. In the Australian context, this proportion translates to almost 2.5 million workers performing remote work at least part of each business week, with almost 750,000 of them working full-time from home. Importantly, these figures are pre-COVID-19 at a time when there was a prevalent belief that remote work would gradually gain popularity. This notion was fueled by a combination of factors, including ongoing technological advancements, evolving lifestyle preferences, the empowerment of individuals, concerns about climate change, the expansion of global manufacturing networks, and the growth of the knowledge economy centred around services. Yet, the COVID-19 pandemic and its disaster management response in the form of social distancing and widespread lockdowns have been a catalyst for the exponential growth of remote work, particularly in its home-based format . The rapid growth of remote work has a significant impact on our cities, altering the spatial distribution of work and workplaces that were originally planned with deliberate separation of land uses. This shifting economic landscape gives rise to numerous implications, such as the need to reallocate infrastructure investments, a changing demand for employment, land and office buildings, shifts in local traffic patterns, the decline of dormitory suburbia, and a necessity to reconsider the design of residential dwellings. Since COVID, these impacts require an urgent and appropriate response from urban policymakers to manage, nurture and accommodate remote work across suburbia, residential neighbourhoods, postindustrial warehouses, large mixed-use development projects, community facilities and the public domain. Such responses will be required because cities are "the absence of physical space between people and companies. They are proximity, density, and closeness. They enable us to work and play together, and their success depends on the demand for physical connection" . Remote work has largely not been addressed by urban policy. Researchers describe its impact on cities as the rise of the post-functionalist city ; the dispersion of economic activities , and; affording new work practices and spatial configurations . Remote work is difficult to capture for the purpose of research and policy development . Its importance has been cyclical through trends such as the growth of the "gig economy," consulting services, temporary contracts, large turnover of microbusinesses or nomadic work practices . Yet, for the remote workers to fully participate in the collaborative brilliance that cities offer, urban policymakers must have a sound understanding of remote workers' needs and preferences, and their daily interactions with each other and with the urban environment. Since COVID this is increasingly a priority as hybrid work continues to evolve . It is still true that the city that understands and caters for remote workers better than other cities is more likely to succeed in the global competition for talent, skilled individuals and entrepreneurship. Remote work has the ability to loosen the shackles between work and the workplace, offering people the liberty to choose their preferred location within a city and between cities, adding to the flow of urban populations, which abandon the less successful places and arrive to those that offer them amenities and opportunities they desire . Our argument in this paper is built around the notion of the changing nature of work.But in what ways is the nature of work changing precisely? This intricate subject can be explained through consideration of the full range of forces that shape work in cities. The nature of work usually encompasses one or more of its four tightly related aspects : • occupation type and its spatial distribution; • content of work ; • organisational, social and institutional context; and • relationship of work with other aspects of daily life. Considering occupation type, one of the most significant changes is the relocation of manufacturing from the wealthier Western cities to countries where labour is cheaper . This adds to the growing polarisation of labour opportunities between high and low skill jobs, despite the growth of the services economy and the creation of jobs and industry sectors that were not around a decade or two ago. Jobs involving a high range of abstract or interactive tasks are emerging, complementarily with new technologies . Skilled individuals who are able to undertake these jobs are likely to gain from the adoption of new technologies, whereas workers who lack such ability will be at risk of losing their job . The second aspect that shapes work is the content, which is the combination of techniques, technologies and skills that are involved. Here, the content of contemporary work is affected by two processes: automation and digitisation. Many activities that workers carry out today have the potential to be automated. This is particularly relevant to routine tasks, and aspects of work that follow well-defined rules that can be automated with rulebased algorithms . Researchers in recent years have pointed to certain jobs in food services, manufacturing, transportation, agriculture, retail and mining as those that have a high automation potential. Whilst the proportion of occupations that can be fully automated is still quite small, less than 5%, the technology has the potential to affect most occupations, benefiting highly skilled workers. Fortunately for many workers, the fact that a job can be automated does not inevitably translate into the deployment of an automated technology due to costs, supply of available labour and a benefit analysis of automation. Another substantial aspect of the impact of technology and skills on work includes digitisation. Digitisation has been described as the process of a socioeconomic change initiated by the introduction of digital technology, the application systems and their production networks . Researchers explain the impact of digitisation through the increase in computer power which, since 1945 has been increasing by 45% each year, bringing about a substantial increase in the affordability of computational tasks . Measuring the adoption of digitisation amongst companies, researchers find relatively large disparities as only a few sectors appear to be highly digitised, including financial services, media and the technology sector itself. Interestingly, these sectors are also among those with the highest productivity and wage growth , whilst many other sectors remain less digitised, including healthcare, education and retail. An interesting observation in this space is that the fast pace of changes to the technology and skills required to perform work created a misalignment with the educational system, with many employers reporting the lack of appropriate skills being the main reason for job vacancies . Whilst technology enabled companies to redefine the way that they operate, it also unleashed the potential of the sharing economy, enabling individuals to increasingly engage in sharing economy ventures such as Uber, Etsy, Airtasker or AirBnB . The third aspect of work, the organisational context, includes flexibility. This flexibility has two sides. Employers see flexibility as an opportunity to focus on their core business elements and outsource non-core activities, such as human resources, accounting, legal or marketing. The most remarkable outcome of this organisational change is the growth of contingent temporary employment focused on the completion of a specific task,of relatively short duration . The contingent work encompasses independent contractors, temporary staff and -more recently -workers participating in the "gig economy," who often deliver work online, without a face-to-face meeting with their employer . The other side of organisational flexibility involves employees and their individual preferences. Contemporary workers want flexible work . Parents with younger children often prefer to work from home at least a couple of days a week in order to spread the working hours across the day to do the morning and afternoon school run, organise the house and be around if something happens. The younger working generation aspires to live like modern nomads, combining travel with work. Experienced professionals, confident about their skills, are often tired of working for a company and feel a desire to work independently, for example, by way of delivering consulting services. This desire for flexibility has resulted in the growth of remote work, benefiting both sides involved in the job contract. Employers, or companies, which offer remote work are able to save money on fixed costs associated with daily business management, including office space and equipment. Remote workers are also reported to be more productive, which is related with increased autonomy, reduced workplace distractions and the liberty to pursue work at times they consider to be the most efficient. In his frequently-cited research into the productivity of call centre workers in China, Stanford University's Professor Nicholas Bloom concluded that allowing employees to work from home can raise productivity . In this study, people working from home were found to be 13.5% more productive than their office-based colleagues performing the same tasks. The productivity benefits for companies are also realised through the ability to outsource their non-core activities, offering consulting opportunities to skilled, independent workers. Further company benefits resulting from enabling remote work opportunities resonate with the workers' individual needs and preferences, which in turn assists in better employee retention, and reduces business disruptions caused by staff turnover. This positive impact on staff retention was demonstrated through a study of 1,202 full-time workers in the US , in which 74% of respondents agreed that the ability to work remotely would make them less likely to leave their employer. Also, over 80% of respondents agreed that this particular work arrangement would make them feel more trusted at work and more likely to recommend their company to a friend. Remote work, particularly home-based, has also proven to be a disaster management response in the COVID-19 pandemic . The fourth aspect of the changing nature of work is the relationship of work with other features of daily life -which brings in the purpose of this paper, which is focused on identifying implications of working from home for the design of healthy work environments. A wealth of contemporary research confirms the importance of cities as facilitators of 'urban buzz': face-to-face interactions where people come together to participate in knowledge dissemination, synergies and spillovers . However, whilst central business districts in cities offer environments for knowledge-based collaboration, surrounding residential neighbourhoods were not designed to perform that role. Yet, for reasons described above, work -more dispersed and flexible -becomes a more common feature of all urban areas . Analytical studies anticipate that work in the future -while often casual, lacking union support and risking precarity -will continue to be flexible and dispersed, with new technologies enabling unprecedented opportunities to work from anywhere . Therefore, it would appear there is an opportunity for urban spaces -including the local neighbourhood -to be designed with opportunities for collaborative mechanisms supporting a city's competitiveness . Since COVID-19, there is a chance to propose a new order for cities and their workers for the post-pandemic urban future . A new order for a sustainable, balanced lifestyle based on the ability to work remotely, spreading economic activities across the city, offering flexibility and work-life balance for workers, reducing congestion and infrastructure requirements for local councils. Yet, this new order requires a sound understanding of remote workers' locational preferences, needs, aspirations, interactions with the central business district and their impacts on residential neighbourhoods. This sound understanding of remote work is needed to plan and respond to the changing economic landscape with its multiple implications, such as a revised approach to the allocation of infrastructure investment, sensible planning for the demand for employment land and office buildings, and the design of residential dwellings. In addition, this requires an understanding of how existing infrastructure will be impacted if workers are no longer accessing the buildings and services within a central location. This paper aims to improve our understanding of remote work by canvassing implications for the planning and design of residential neighbourhoods that are conducive to working from home , and; the design of healthy work environments at home . The remainder of this paper is thus structured in two parts: In the next section, we look at findings from a survey conducted by the City of Gold Coast in Australia exploring the spatial distribution of remote, nomadic, and home-based workers in cities to discover certain socio-economic, design and built environment features that relate to this distribution. This illustrates the impact that an uptake of home-based work has for urban planning and design. In Section 3, we examine some of the working from home implications for career progression, productivity, physical and mental health. Based on a review of relevant literature from architectural science, environmental psychology and design, this section employs human-building interaction design scholarship to argue for the design of healthy work environments at home in order to increase productivity, reduce sick days, and yield better health outcomes for the home-based work force. --- "You're on mute" -Home-based work in a lifestyle city In late 2020, amidst the COVID-19 pandemic, the City of Gold Coast in South East Queensland, Australia launched an online survey asking the city's residents about how work from home changed the way they interact with their neighbourhoods. Notably, at the time of deploying the survey, the Gold Coast had not experienced a severe wave of COVID-19 as Australia closed its borders in early 2020; Gold Coasters pursued work from home in accordance with government guidelines, yet many experienced a relatively unconstrained life within the context of an isolated island continent. Required to work from home wherever possible, yet free to move around within the state of Queensland, the city's residents explored how work from home impacted the way people engage with their cities, neighbourhoods and homes. By way of background, Gold Coast, Australia's fifth largest city with a population approaching 700,000, originates from a network of beachside villages, established by local, Queensland-based holidaymakers in the 1870s. Pleasant subtropical climate and beachside location have contributed to the rapid evolution of the Gold Coast into one of Australia's largest cities and a popular holiday hotspot, attracting 11.4 million visitors in 2022 -still down from the industry peak of 14.4 million visitors in 2019 . Recently, the city's popularity as an amenity-driven destination has had a role in diversifying the city's economy , with strong employment growth observed in sectors such as digital creative services, freelancers/sole traders, and consulting organisations, with a high proportion of home-based workers moving to the area from interstate or abroad. The COVID pandemic seems to have accelerated interstate migration to the Gold Coast, in line with observations made by researchers with respect to other 'sunbelt' cities . The Gold Coast survey, conducted by the local government in collaboration with a local university, identified a set of 22 urban activities, such as "visiting a local café," "interacting with the neighbours," "driving on the motorway," "visiting the local park" or simply "going to the local beach" . The survey asked the participants to rate the impact that home-based work had on the frequency of these activities as: more oftenslightly more often -no change -slightly less often -less often. The survey received 887 completed responses and its results revealed that the impact of home-based work on the way people interact with the city is location-driven, or more precisely, amenity-dependent. In the attractive coastal parts of the city, where denser urban environment and frequent public transport enable better access to the urban and natural amenities, respondents reported an increase in frequency of visiting local cafés, neighbourhood shops, riding a bicycle instead of a car, and accessing local open spaces, including more frequent trips to the beach. In this part of the city, respondents reported more frequent interactions with their neighbours . However, the study delivered somewhat different results for the Gold Coast's central suburbs where the built form is car-oriented and dominated by detached housing. Here, the impact of home-based work on urban interactions was less visible and mainly included increased patronage of locally available open spaces. Lastly, the city's hinterland, naturebased areas, located away from the coast and dominated by a high proportion of hobby farms and heritage villages delivered different observations. Here, the respondents reported more frequent walking and cycling trips and the frequent use of locally available open spaces. Interestingly, the frequency of shopping locally decreased. Regardless of the location, the survey participants reported an increased frequency of walking and cycling, and a reduced use of vehicles and less frequent trips on the main motorway connecting the Gold Coast with metropolitan Brisbane to the north. Findings of this survey are interesting on many levels: firstly, they offer insights into the ongoing evolution of residential neighbourhoods towards live/work communities, with all consequences for town planning, public transport and amenity impacts. Secondly, the survey highlights the role of local amenities in attracting skilled individuals to move in and pursue work from home, and; creating opportunities for ongoing social interactions and work-related collaboration. Thirdly, the survey offers an opportunity for other cities competing for skilled, independent individuals to conceptualise the preferred urban environments -including design of individual dwellings, which are able to attract and cater for the needs of home-based workers. The survey supports the notion that attractive amenity-driven destinations are concentrated in the affluent beach-side suburbs and in scenic hinterland valleys. Moving forward from this observation, home-based work seems to cause gradual, unplanned shifts in a city's urban and economic fabric by way of concentration and enhancement in desirable neighbourhoods that cater for educated and experienced professionals. In these neighbourhoods, home-based work post-COVID is becoming spatially significant, with often more than 20% of employed residents working from home . In these locales, home-based workers are engaging with their neighbourhoods in a different way than people who commute to work, with increased preference to visit local shops, restaurants, cafés and parks, in a sense enhancing the "urban village" aspirations of contemporary urban planners . The other side of this picture is that neighbourhoods unable to attract home-based workers due to limited availability of urban or natural amenities are likely to stagnate. Without a natural environment enhancing amenity-led migration, certain parts of urban neighbourhoods can only account for attractiveness of the local economy and human capital strengths to determine whether they will host home-based work communities or not . Gold Coast is an example of a tourism centric coastal city, albeit one that is rapidly growing and diversifying and features a range of neighbourhoods in addition to the ocean adjacent suburbs. This single case study cannot be representative of all cities. However, what appears to be emerging from the Gold Coast study, is that the future of work may be changing in a way that impacts the economic geography of cities in diverse ways even within a single city. Frequency of home-based work will likely continue to vary across and within cities. Therefore, there is a need to monitor and push back against polarisation of neighbourhoods, ensuring equal access to amenities and opportunities for all residents across and within cities and regions. Building upon the findings of the Gold Coast study, it becomes crucial to not just look at the macro-implications for urban planning but also address the implications of this evolving work landscape on the wellbeing and productivity of individuals working from home. In light of this, Section 3 now delves into the design of healthy work environments at home, emphasising the significance of Human-Building Interaction design scholarship and its potential to foster improved health outcomes and overall work performance. --- Designing healthy work environments at home The findings of the Gold Coast survey offers evidence that the COVID-19 pandemic has significantly changed the way we live and work. The rapid advancement of online technologies has enabled people to carry out many work tasks from home . This has led to a significant increase in flexible working, which combines remote and in-person work, and this trend is expected to continue in the coming years . While working from home can provide a greater sense of autonomy , it can also have implications for career progression, productivity, and physical and mental health due to the extended periods spent at home with limited social interactions . The long-term effects of this relatively new shift in working conditions are yet to be seen; however, considering the substantial increase in flexible work arrangements and the likelihood of some jobs becoming permanently remote , more attention to the potential impacts and strategies to mitigate them are needed. One approach to investigating and developing strategies to mitigate the effects of remote working is through the lens of Human-Building Interaction . The HBI lens focuses on designing physical spaces that effectively integrate technology and usability, with a strong emphasis on the human-centred perspective . While pervasive building technologies have been employed to inform users of indoor conditions in the context of Indoor Environmental Quality design , little attention has been given to the impact of environmental conditions on career progression, productivity, and overall wellbeing when work is conducted from home. There is a need to explore how the HBI lens can facilitate viable alternatives to communicating other variables that support positive decision-making processes in residential settings. For example, this could involve defining optimal times for taking breaks, engaging in conversations with colleagues, or spending time outdoors or in community settings. A crucial aspect tied to the impact of remote working is the home office environment. While the COVID-19 pandemic led to a surge in home technology purchases and technology acceptance worldwide , it is important to recognise that other environmental, spatial, and social factors within the home environment can also influence the experience of working from home . Factors such as access to operable windows for fresh air, daylight, and opportunities for mental recovery, as well as being in contact with pets and family members, and proximity to parks or other green spaces can significantly impact both the physical and mental well-being of individuals, ultimately affecting the quality of their work and work-related connections. The HBI lens can offer valuable insights into understanding the links between the environmental quality of a home office and the attitudes and behaviours of individuals working in that environment, enabling improvements informed by iterative use. The following subsections provide an overview of the primary challenges associated with remote work in terms of career progression ; productivity , and; physical and mental health . --- Working from home and career progression Limited face-to-face interactions with colleagues and supervisors can significantly impact job opportunities and career advancement . Unlike spontaneous interactions that occur organically in the workplace, planned online activities such as virtual meetings do not provide an equal substitute, despite remote workers potentially putting in longer working hours than their office colleagues -often one or two full-time days per week . This shift in the way people connect and work post-pandemic can lead to two detrimental factors for career progression: social isolation and burnout. Social isolation, characterised by a sense of deprivation from human contact, is prevalent among those working from home . The long-term consequences of social isolation may decrease work engagement and productivity and increase job-related stress . Although research indicates a decrease in absenteeism for those working from home , health factors such as anxiety, depression, and stress are tied to increased leaves of absence from the workplace . Burnout occurs when people dedicate excessive time to work or constantly worry about it, often resulting in prolonged absences from work . Extended leaves of absence are often associated with slower career progression, implying that remote workers may experience long-lasting impact on their employment status due to the shift in work dynamics. Furthermore, studies show that remote work is predominantly chosen by women who already face a gender pay gap and imbalances in career advancement compared to their male colleagues. Thus, remote work has the potential not only to affect career progression but also to widen the pay gap between male and female workers. The HBI literature poses some alternatives to address imbalances in career progression due to remote working. GPS, GIS, and accelerometry technologies have been extensively used to study positive decision-making habits linked to adolescents engaging in physical activities outdoors . Thus, similar home-based technologies can be designed to facilitate networking opportunities among colleagues living in proximity, in line with initiatives oriented at mapping neighbourhoods to promote physical activity in children . This could involve mapping satellite work centres at a walkable distance from home and identifying public spaces that strengthen opportunities for networking and career advancement . Other initiatives could be implemented for workers living in different cities or countries, including the use of advanced visualisation technologies such as Augmented Reality to instil a sense of community from the distance, in line with interventions to promote remote collaboration among students . By promoting health-oriented decision-making practices, these initiatives can help reduce feelings of isolation and burnout, potentially mitigating their impact on career progression. --- Working from home and productivity While studies have suggested that working from home leads to increased productivity due to the additional hours spent on work, other studies have indicated that working from home in a full-time, mandatory capacity reduces productivity . Environmental factors at home may help to explain this phenomenon, as individuals spending extended periods in an unchanging environment are more susceptible to distractions . Additionally, the decline in third places -i.e., liminal spaces that help separate work from leisurehas become evident with the rise of remote work . Therefore, it is crucial to prioritise creating opportunities for positive distractions in home offices, as well as to map environments conducive to attention restoration near homes. Research on attention restoration highlights the importance of natural spaces and features on positive mental states , enhancing creativity and overall wellbeing, while providing a break from focused work. Thus, reinforcing these conditions within the home environment can help foster mental states that positively influence productivity while working from home. Some HBI literature proposes creative solutions for enhancing engagement with positive distractions in the workplace. For example, virtual reality interventions have been effectively used to foster relaxation among office workers, yielding positive physiological arousal and affect responses . Thus, a similar approach can be applied to remote work settings to foster positive distractions among individuals. Researchers have indicated that desk sitting does not necessarily correlate with work productivity , suggesting that other indoor nudges or technology-driven strategies may be more effective to increase productivity at home. To achieve this, establishing connections between environmental measures and personal measures could serve as a first step in encouraging remote workers to engage in positive distractions, such as active desks , artificial windows , or other similar interventions contributing to an overall increase in positive distractions at home, and consequently, in remote work productivity. A different strategy would be designing pervasive technologies that enable focus in workers dealing with concentration issues at home . For this group, pervasive technologies and personal comfort devices could be customised for home offices to maintain preferred environmental conditions for sustained concentration. While current technologies make this a feasible solution, more research is needed to understand how this approach can be adapted to various spatial and individual circumstances, ensuring it meets the unique productivity demands from individual workers. In addition, we note that modifying a home working environment may not be possible for some people due to cost, space, and knowledge, and therefore additional research is needed to understand the affordability and feasibility of these options. --- Working from home and physical and mental health One of the most concerning effects of remote work is the rise in sedentary behaviour. Research shows that individuals who work remotely tend to have reduced incidental time spent outdoors and consequently, engage in fewer outdoor physical activities. Sedentary lifestyles are closely associated with negative health outcomes, such as poor sleep and chronic cardiovascular diseases . Although the transition from office-based work to remote work is relatively recent, it is possible that remote workers may now experience more symptoms associated with sedentarism. Moreover, remote work is also linked to moderate to severe physical discomfort resulting from ergonomic issues in the home working environment . Previous research recognises the importance of integrating technology with effective decision-making strategies to promote healthy behaviours among urban residents. For example, the use of design interventions to encourage individuals to take active breaks through the gamification of public space . Likewise, smart furniture has been previously developed to increase physical fitness among remote workers within indoor environments. Using GPS technology to map nearby parks and green areas, as well as using Internet of Things to inform the design of indoor furniture and work-related devices may effectively increase mental and physical wellbeing among remote workers. To complement some of these technical solutions, it is crucial to also consider associated non-technology recommendations such as new workplace policies tailored to remote work, focusing on worker health and wellbeing. Workplace policies can promote a healthy worklife balance by setting clear boundaries between work and personal life, establishing specific working hours, and encouraging regular breaks and physical activity. Additionally, organisations should prioritise mental health support for remote workers, such as providing access to counselling services and promoting self-care practices. Implementing regular check-ins and fostering social connections through virtual and face-to-face team-building activities can help to further reduce social isolation and promote a sense of community among remote workers. In addition to the local realm, the implications of remote work call for considerations beyond individual home offices. Urban planners should recognise the shift in work dynamics and explore ways to adapt public spaces to accommodate remote workers' needs. This could involve policies and regulatory frameworks to enable the creation of coworking spaces within residential neighbourhoods, providing opportunities for remote workers to interact and network with others in their community. This may require rezoning some areas to allow for mixed-use buildings, instead of only residential, to accommodate local amenities such as cafes or small commercial establishments. Furthermore, planners and landscape architects need to prioritise the integration of green spaces and parks into residential areas to provide remote workers access to outdoor environments that promote physical activity, relaxation, and attention restoration. Equitable access to these spaces is important to ensure benefits are not just experienced by higher socio-economic groups. By incorporating these elements into urban planning and design frameworks, cities can support the wellbeing and productivity of remote workers and create a more balanced and livable environment for all residents. Having examined some of the implications of home-based work on career progression, productivity, and physical and mental health, we now conclude the paper highlighting the importance of incorporating such a dual perspective that combines the macro-view of urban planning and design with the micro-view of designing healthy work environments at home. --- Conclusions The COVID-19 outbreak has resulted in the exponential growth of remote work, with homebased work becoming a standard work arrangement for many office workers. We propose a fresh perspective on the positioning of residential suburbs, suggesting that specific neighbourhoods should shift away from being solely dormitory suburbs and transition towards a mixed or multi-use model, where living and working functions coexist. The growing prevalence of work within residential areas has profound implications for the way people move within the city and their work practices within their homes. Moreover, the increasing number of residents working from home or nearby locations should prompt a reevaluation of other urban life aspects, including recreation and leisure activities. There are many built environment features positioned by the development industry as appropriate design solutions enhancing and accommodating remote work. Zenkteler et al. suggest a taxonomy of key/frequent features of live/work developments comprising origin, composition, movement and lifestyle. Based on findings from Section 3, we present Table 1, which extends this work to also incorporate health and wellbeing considerations. --- Movement No larger than a circle with a 1-kilometre radius, to allow a maximum of 15 min walking distance Shared working spaces located in walking distance Neighbourhood designed to minimise car trips and promote walking and cycling --- Lifestyle Flexible working time of the residents enables them to experience a variety of places and spaces located within one neighbourhood. allows experiencing different aspects of urban space at the same time Workspace and living space within dwellings connected but separate, so that the workspace can be easily accessed by the owner from the residential part and by staff/associates without impacting on the residence Live/work studios have 100m 2 to 250m 2 overall size of dwellings with up to 50% designated for workspace Strong community focus, with community organisations, communal works, central hubs for shared activities. --- Health & Wellbeing Designing healthy work environments at home is crucial to address the challenges of remote work, such as career progression, productivity, and physical and mental health. The concept of Human-Building Interaction offers valuable insights for improving remote work conditions by integrating technology, usability, and a human-centred perspective. Career progression may be hindered by limited face-to-face interactions, leading to social isolation and burnout. HBI can provide solutions like mapping nearby work centres and utilising advanced technologies for networking and community building. Productivity in remote work can be influenced by environmental factors and the decline of third places. HBI suggests creating opportunities for positive distractions and mapping attention-restorative environments near homes. Sedentary behaviour and ergonomic issues are concerns for physical and mental health in home-based work. HBI recommends integrating technology with design interventions to promote active breaks, utilise smart furniture, and incorporate GPS and IoT technologies for enhancing health and wellbeing. Most contemporary suburbs -built with intentional land use zoning that separates different land uses -have not been planned and designed with these features in mind. In the longer term, this may exacerbate challenges associated with remote work, such as social isolation, limited opportunities to collaborate or socialise, access to work-related services, and access to green spaces for mental breaks and attention restoration. Zenkteler, Darchen, et al. suggest that there is a need to develop planning interventions at the city-wide scale. In light of COVID-19, which has caused exponential growth of remote work, holistic, city-plan or region-wide remote work strategies are warranted more than ever, keeping in mind that remote work is not equally distributed within cities -it is highly concentrated in suburbs of certain socio-economic attributes. Consequently, city-wide strategies should lead to site-specific interventions, employing community participation . The findings presented in this paper emphasise the need to incorporate live/work features in residential neighbourhoods, where work and leisure activities now coexist due to the changing nature of work. While some new research in response to this trend is emerging , further work is required. Our conclusions align with the overarching theme of this special issue on "Homes that Work," which explores the implications of the COVID-19 pandemic on the various scales of the built environment. By challenging the traditional notion of home as purely domestic and acknowledging the trend of integrating new work practices and workplaces within residential contexts, we can strive towards creating inclusive and healthy work environments that offer high quality space to foster both productivity and wellbeing at the same time.

Remote work in cities is growing in popularity, fuelled by ongoing technological advances, the globalised knowledge economy, changing lifestyle preferences, the need to empower individuals, and -more recently -the effects of COVID-19. Social distancing measures introduced during the pandemic have inadvertently shown that a substantial proportion of work can be done from home or from third spaces such as co-working spaces. This paper offers a critical appraisal of the implications of this trend for neighbourhood planning and workplace design. This appraisal is structured in three parts: First, to set the scene we review recent scholarship on changing work practices in the post-pandemic city. Second, we offer a summative account based on empirical data from a survey conducted by the City of Gold Coast in Australia. This survey explored the spatial distribution of remote, nomadic, and home-based workers in cities in order to discover certain socio-economic, design and built environment features that relate to this distribution. This illustrates the impact that an uptake of home-based work has for urban planning and community design. Third, we look at some of the working from home implications for career progression and productivity, as well as physical and mental health. Based on perspectives from architectural science, environmental psychology and design, this part of the paper employs human-building interaction design scholarship to argue for the design of healthy work environments -both at home and in neighbourhoods that increase productivity, reduce sick days, and yield better health outcomes for the home-based work force.

Introduction This paper investigates how various types of self-tracking users influence the health practices of others living in the same household. The study benefits from an international perspective, but shares limitations with previous research on health behaviour by focussing on those who live in locations with high levels of technological use. [1][2][3][4] The empirical data examines household tracking practices to investigate how different trackers contribute to new cultural and social factors affecting health across life stages. Nettleton and Green 5 propose the context of 'social practise' to best capture the complexities and interconnectedness of health structures and examine why practices change. In this case, they argue for a shift in perspective: 'to think of physical activity not as a form of health behaviour, but as a mode of social practice.' 5 . Drawing on the classic work of Giddens' 6 and Bourdieu's 7 conceptualisation of social practice, Maller considers the need 'to better understand the dynamics between agency, structure, daily life, health and ill-health' 8 . Ajana's work on self-tracking surveillance highlights the significance of individual and collective subjectivities in considering social practices formed within digital health culture and quantified self-identities. Where, the conditions of digital health culture should be examined, 'not only in terms of online forms of health-related biosocialization, but also with regard to the offline meetings facilitated by self-tracking communities.' 9 . This article delves more deeply into the intersection of such online and offline dynamics to describe the social practice concerning digital health culture and shed new light on issues of structure and agency in households sharing self-tracking experiences. health practise and produce different outcomes for patients outside of the traditional clinical setting. [10][11][12] Self-tracking technologies, in this context, are part of an always-on culture that is changing how young people in particular, communicate and interact with health information. 13 Régnier and Chauvel 14 raise new concerns about the growing digital divide and health disparities associated with this self-tracking culture. In their study of middle-class self-trackers in France, they observed significant individual change most often following a major event in the participants' life course ; noting how 'the middle class perceives the use of self-tracking as a way to access the practices of the next highest social group to which they aspire.' 14 . The perceived high social status of wearable tech and access to sophisticated smartphone apps should be viewed as integral to self-tracking health culture and, in turn, social practice. In other studies, the social well-being consequences of health tracking are well documented, focusing on a self-care body ethic and preventative illhealth culture In this regard, there is growing interest in the various ways self-tracking technologies are socially and culturally relevant with significant health implications 4,16,17 . The value of a shared health culture grows, as evidenced by the conditions for achieving health goals in an online and offline environment where new forms of social practise are enacted as part of self-tracking. 9 Against this backdrop, it is worth noting that there is no universally accepted definition of self-tracking culture. Hofstede defines culture as 'the collective programming of the mind which distinguishes the members of one group or category of people from another.' 18 . When applied to self-tracking, Hofstede's work relates to a broader sense of health culture or being healthy founded on shared values practised by a specific group of peoplesuch as the 'quantified self' community. 19 When paired with what Beer 20 observes as the 'by-product' of digital data, digital forms of health interaction create new opportunities for social practice. As a result of self-tracking becoming a well-established feature of daily lives, we can distinguish how it affects individualised health practises and their overlap with proximate others. 16 Indeed, our understanding of self-tracking as a cultural phenomenon is incomplete unless we recognise the appeal of the health data beyond its 'allure of objectivity' 19 . Moreover, and crucial to the arguments advanced here, the conditions of health change should be read in the context of the specific social and material environments from which self-tracking derives its meaning. In their study of interpersonal relationships in the home, Neustaedter et al. 21 observed how technologies change people's awareness of routines and group dynamics. The study helps us understand how mediated interactions and data become integral to family routines, both 'articulating and verifying the everyday mundane that people are familiar with.' 21 . Pina et al. 22 observe how 'Family-centred informatics would take advantage of shared daily experiences to allow one family member to add information on behalf of others.' According to Pina et al., self-tracking technologies and health self-management have a 'ripple effect' within households, improving family awareness and health goals. 22 . One of the study's recommendations is to understand the opportunities for family-centred health informatics and to address family health as a whole. The way health tracking is embedded in the physical environment of the home will aid in the analysis of the various experiences for acquiring self-tracking skills and the conditions for achieving health goals. Reflecting on these studies, we need to understand the conditions that enable such family/home-focused health practice. Here, the proposition is to examine alternative forms of knowledge to explain how and why health practices are transformed within the home. While the emphasis is on self-tracking and health data as extensions of everyday tech-driven culture, the findings presented in this article have a subtext. Indeed, they should be read in response to Pina et al.'s 22 call to investigate the contours of family informatics to gain a better understanding of family health monitoring practices. According to Grimes, Tan and Morris, 23 family-based education 'demonstrated [the] importance of modelling, praise, and family interaction' to facilitate discussions about living healthier lifestyles. This type of facilitation has significant implications for understanding an emerging 'digital-sharing' culture in which health practices recursively fold back into and reconfigure health behaviour 24,16 . Thus, household self-tracking can in part make this sharing and recursive loop of new health social practices visible. The central idea is that households are changing the contextual experience of health tracking and opening new spaces for empowerment. For example, Aarhus and Ballegaard 10 emphasise the importance of self-care opportunities outside the clinical setting and integrating health management with other activities in the home: 'to establish routines allows the disease to step into the background.' Such integration considers the practicalities of health at home, how this alters our perception of illness and how selftracking practices provide health empowerment. Despite the potential for empowerment, Will et al.'s 25 study on selftracking in older couple's intimate relationships emphasises the emotional and physical vulnerabilities associated with a partner's involvement, as well as more traditional forms of control . In contrast, Loe's 26 research on the use of health technologies by women nonagenarians, the majority of whom lived alone, reveals a set of health practises centred on a self-care ethic around independence: 'about accomplishing and maintaining a broad sense of health that involves comfort, confidence, continuity, autonomy and social capital in the context of old age. ' The question here is how health data and self-tracking practises reshape and rework one's perception of health culture. For instance, Yamashita et al. 27 argued for the importance of family health tracking in developing coping strategies between family caregivers and care recipients. Elsewhere in computing scholarship, Ferdous et al. 28 have built a persuasive case of what they refer to as 'everyday commonsensailty' as enhanced family experiences through digital augmentation centred around family mealtimes. This study of ICT usage and mealtimes show how recurrent patterns of social interaction, such as those that characterise family dinners, can be examined for ways they reinforce social relations. The surrounding social and cultural structures have important consequences for understanding how and why health practices within households may change: 'not least because how and why people act as they do is likely to be beyond their cognitive and rational understanding' 5 . One explanation is the emphasis on self-improvement that has long been prevalent in Western cultures and is an essential aspect of selftracking; as Lupton 29 observes, 'you are your data'. Such individualised perspective is consistent with recent health surveillance research, which shows that health data enact a specific version of the social world, namely the normalisation and objectification of individual experience. 30 This central premise is evident in Jørgensen et al.'s 31 study of children's health activity tracking by parents: 'the data sometimes reassured parents on the children's physical activity and sleep […] Also, often the children felt under surveillance.' While health data tracking opens a new set of analytic possibilities in which individuals seek to have an active attitude towards health, there is also a 'dark side'. 30 As stated by Jørgensen et al., 31 we should be aware of the risks associated with monitoring physical activity in the home, particularly in terms of how health surveillance is brought into family settings and the longer-term orientation of the cultural value of self-tracking practises. Other researchers have demonstrated how technologies help loved ones feel connected to each other can enhance caring intimacy, outweighing the risk of data surveillance. 32,33 Considering 'care at a distance' for households in Japan Hjorth and Lupton's 16 study demonstrates opportunities for new intimacies supported by enduring patterns of social interactions and care that characterise a broader digital health culture. Turning the focus away from the individual tracker and towards the relational and cultural aspects as a mode of social practice is an excellent place to start when examining household tracking. --- Research methods This research was a qualitative study of participants in major cities in France, Italy, Spain, the UK and the United States. Data were collected over 6 months, following a pilot study with participants who self-identified as 'experienced and dedicated trackers'those with more than 2 years experience of recording health data and maintaining daily fitness activities. Following approval from the institutional ethics committee, participants were recruited using purposeful sampling and snowball sampling techniques. 34 A social media survey about self-tracking was distributed through independent health fitness clubs and online running communities, targeting long-term daily self-trackers. Among respondents, 346 individuals lived in a household where they were the first to adopt self-tracking activities. The survey had a higher response rate than expected and likely due to people spending more time on social media and attention to health and fitness posts during national and global COVID-19 restrictions. Following post-survey invitations, 35 households agreed to participate further. Table 1 shows an overview of the household demographics, including the numbers of new and experienced trackers. Everyone over the age of 19 years in these households agreed to participate in the study for the duration. The paper's findings include 13 households with a diverse mix of trackers and age ranges to consider entanglements of kinship and care across digital social and material contexts. Excluding dependent children , there were 16 experienced trackers aged 19-54 years, 11 of whom were male and 5 of whom were female. Participants who were new trackers ranged in age from 19 to 98 years old, with 13 female and 6 male participants. Households were stable in the sense that their members had lived together for at least 18 months; five had dependants under the age of 13 years, and three had elderly relatives . Four households lived in rented housing, while nine lived in mortgaged housing. All the participants were employed with a steady income or enrolled in full-time higher education. The number of languages spoken in the household was asked to indicate multiple literacies and intergenerational arrangements for health support in the home Slightly less than one-third speaking a single language, more than half speaking two languages and three households speaking three or more. Semi-structured interviews were conducted via Zoom lasting for 45-90 min. Households were interviewed on three occasions with newly emerging themes each time informing the next stage of data collection. Interviews were ordered as follows: 1. The first interview focused on how tracking as a household came about; 2. The second interview focused on changes within the household; 3. The third interview was a 'hindsight exercise' in which participants reflected on their shared accounts of tracking. The interval method was intended to capture the 'co-evolving' aspects of tracking and the communicative possibilities of self-improvement through tracking. Interviews were organised so that household members could join the discussion together. The purpose of the discussion was to allow shared narratives in a real-time setting that could be explained or corrected between household members. 36 Will et al. 25 discovered similar emerging dialogues in interviews with couples about tracking. The digital interview settings offered some exciting possibilities for qualitative interviewing. 37 The setting included fitting participation alongside other demands within the home. Participants could prioritise caring tasks elsewhere and take turns responding to questions. Household members wanting to offer spontaneous or fleeting contributions could do so by moving into the interview 'space' and joining the Zoom call. Interview transcripts were read and reviewed at each interval for patterns to emerge at one stage and be translated into the next, allowing for ongoing comparison of results. The qualitative data was analysed with 'in vivo' coding, which relied on terms used by the participants, and then 'constructed' coding, developed by the researcher. 38 Household codes were compared to each other to generate dominant and counter themes, going back over and reviewing each set of interviews and running queries in NVivo to check consistency and accuracy. 39 The quotations in this article are taken verbatim. The ellipsis dots indicate that minor edits were made to improve readability. In the first section of the findings, I consider tracking transference, which focuses on a households' resources and self-tracking practices. Next, I discuss co-tracking enabling new joint health practices. In the final section, I focus on intergenerational relationships and how households were making sense of health change. The participants' identities are coded and related to Table 2. The coding includes the household number, gender, age and location; for example, refers to Household 1, female, aged 39 years, located in France, shown in bold as an experienced tracker. --- Findings --- Tracking transference Transference practises were identified in the modes of tracking behaviour, describing how individuals sought to work on themselves while also improving the lives of those around them. Tracking transference defines the new types of knowledge associated with health tracking, as well as how the household unit introduced new opportunities to capture and 'read' various types of health data together: We have a daily routine where I get up and the first thing I'm out of the house on a run while my family sleeps […] As a family, we are useless about discussing things, especially health issues. We communicate reasonably well together about everyday things, but personal stuff is more difficult. We care about each other, and we can talk about various health problems in our friends' lives and stuff like caring for others […] About six months ago I decided to take my health seriously and was delighted that my family was involved in my success of weight loss […] we began to look at all of our health habits and to see if we could find a way for the family to do the same thing. The above experiences show an evolving culture of health and fitness and are led by self-monitoring methods. For H1, transference influenced the fitness routines shared between mother and son, and in later interviews, the health information shared with the grandmother. The transference experience was slightly different in H2: 'talking about' personal change created an opportunity to start related, deeper conversations about health here. In parallel, the father had noticed his 10-year-old son's interest in health 'because we [mum and dad] are tracking'. In H3, one partner's decision to 'take [his] health seriously' enabled the transfer of deeper health narratives between experienced and new trackers building on existing interpersonal relationships. 21 When self-tracking became routinised within a household, this facilitated further health discussion and activities. This contrasts with attempts by participants in Will et al.'s self-tracking study to '"draw lines" around appropriate involvement from a partner' 25 . The focus on different types of tracking technologies is a crucial difference here. Tracking is an extension of social practises within households in this study, compared to tracking care within families, specifically through blood pressure and weight concerns in Will et al.'s 25 study. In this study, contrastingly, the experience of tracking enabled new ways to understand health, with broader implications for the household. One reason for this may be the household setting with less emphasis on clinical and medical health practices. 10 With the emphasis on family structures in previous studies 25,17,32 , tracking transference is also evident here in cohabiting households: We took the piss a bit at first He [housemate] was wearing his Garmin all day: when he was in bed, and when he had dates over to stay the night […] but last summer my dad had a health scare and I was scared about the state of my fitness […] because I knew he [housemate] was self-tracking, I started to rely on him for information about diet, food and fitness. I've just started training with him properly and we compete as housemates. While tracking might be noticed for its mundane data capture, the experiences in H4 reveal how tracking behaviour by a non-family household member was an incentive to take action concerning health. 40 Adding to the evidence that tracking health behaviour transfer was a positive experience outside of intimate couple relationships. The self-reported nature of health data effectively allowed members in H5 to understand how health information relates to the intimate and personal space of the household. The tone here contrasts the close intimacies of other households, with humour helping to establish rapport and engagement with health data. For new trackers, it was crucial to see everyday monitoring behaviour in close proximity. This pushed people to alter their behaviour in addition to noticing a difference in the health of others. My daughter [aged 34] enjoys her running so well. She's such a strong young woman in herself. I can see that her confidence has shifted, and how she first places her health and diet. When she has a PB [personal best], she tells me. It cannot be easy for her to still be living at home, but I trust her to know her health and to learn how we can be fit for each other. I've enjoyed tracking things together. Watson et al. 41 further highlight the complexities and relational pressures in which social intimacies might be sustained in their study of sociality during the COVID-19 crisis. For example, H4 anticipated a 'bad' health outcome if they continued to smoke and had begun considering tracking elements to provide new motivations to 'nudge' them towards healthier behaviours. Therefore, in this study and others, households serve as critical spaces that shape people's health behaviours and identities, potentially mitigating the intense scrutiny associated with sharing health data and providing new opportunities for reflection. 23 --- Co-tracking and caring If attention to health data was a catalyst for new users to become interested in tracking, so too was the desire for body transformation. Weight loss, muscle definition, feeling healthy and strong and the desire to achieve fitness goals were frequently mentioned as ways in which new trackers modelled their goals on experienced tracker The siblings' perspectives demonstrate a 'ripple effect' in increasing family awareness about health via technology. 22 Tracking became part of the 'natural conversation' within their household, sharing experiences about health and forming new and profound ways of managing fitness and expressing care for each other. The reference to 'big gains' suggests the performative quality of some of his tracking outcomes 12 but is also connected to a desire for other household members to gain confidence. Aesthetic goals were more strongly evident from households in the UK, Spain and the United States . This theme's prominence may reflect the rapport established with those households during the interview, during which this type of information was more readily shared. This may also indicate that these households participated in a more goal-specific set of health activities centred on weight loss. Three of these households had members in their late teens and early 20s, when appearance concerns are more pronounced as they enter adulthood. 42 In H6, the communicative value of tracking is paramount. A combination of their peer relationship and living together helped to situate their personal needs into a broader set of health and caring activities. 17,23 Co-tracking formed a vital part of the siblings' relationship. Early in the interview exchanges, the siblings talked of co-tracking practices, sharing data to feel 'closer together'. While there are performative aspects too , both engage in tracking to facilitate new forms of health behaviour embedded within the social practice. 5 Moreover, the performative aspects may reflect the popularity of fitness-sharing on social media among young people 11,13 rather than a self-indulgent sensibility. It was observed in later interviews with H6 how the entire family is 'super fit now', indicating a personal level of concern for and active engagement with the family's health within the household. In line with Ferdous et al.'s 28 observations, personal advancement was made possible by data comparison with other trackers. Co-tracking, thus, helped loved ones to add value to existing relationships. There is a new dimension to tracking here where co-tracking offers new caring opportunities shared within households. This perspective contrasted with the individualistic and competitive motivation for tracking. Indeed, it was observable in the care characteristics within the household through repeated tracking performance and practices. The symbolic meanings attached to technologies by how we might care for each other were evident in the construct of co-tracking. Co-habiting partners in H7 discussed adopting a new regime in the aftermath of redundancy: My partner went through redundancy and she was really suffering badly from mental health and physical health issues as a result. Although we were good financially, it was unsettling. I'm the main user of health apps in the family and during this time I purchased us both a smartwatch. I remember getting up one morning and she had started reviewing her health data, and she wanted me to understand this. It was great to see her improve and get involved in life again. We needed to come together like that. The smartwatch was symbolic of an extension of care, reinforcing Yamashita et al.'s 27 shift to more nuanced accounts of tracking and the complexities added with the involvement of intimate partners and caregivers. Similarly to H6, the motivation to share health data and engage in co-tracking activities reflected a desire to look after and care for each other. Further scrutiny is needed to determine the appropriate levels of tracking involvement by close family members. 17 For the members of H6 and H7, we might conclude that as they are younger than the adults in Will et al.'s study, there are fewer complex needs that could add layers of concern around tracking. The difference in national healthcare systems is relevant for H6 and H7, with H6 in the United States being a privatised system and H7 in France being a universal healthcare system financed mainly by government health Hardey insurance. H6 expressly mentions long-term goals and change. H7's use of self-tracking was initially limited to providing support following a major life event. 14 Other factors influencing these reactions include the participation of experienced trackers, who helped address concerns for new trackers within existing social structures and enhanced household experiences. 28 For example, the social affordance of the household was significant in determining the conditions of self-tracking in H8. Since I was at university, I've always run and recorded my times and my changes in pace. My training has become something we talk about as a family. Then it's become something to do together […]I'm competing against people I live with and I see every day. This has radically changed how I train. I am more committed and stricter with my diet and much more aware of the effect on my health because of the people around me. H8 discussed how they would use tracking to 'check-in' on each other. Including how m34's mother would track the data on his Strava account to ensure he was meeting his health goals. This study shows a significant correlation between intergenerational health prompts and support for improving household awareness. 22 Indeed, the intersection of age, ageing and technology raises some intriguing tracking questions, which will be addressed in the final section. --- Making sense of health change While previous research has demonstrated that trackers benefit from materialistic incentives such as reduced health insurance premiums or free goods and services, 24,43 making sense of and maintaining health change within the household was the primary reason for participants in this study to continue tracking. Using self-tracking, households established whole new routines for maintaining health regimens: Traditionally, I've been the one to shop and cook all meals, and now we're sharing a lot about healthy recipes and planning special occasions so that we can maintain a healthy lifestyle. We cut sugar, absolutely The members in H9 value the 'collective' decisions about diet and exercise made inside the home and devote considerable time and effort to recording meals and exercise regimens. 23 In comparison, the validation of change in H10 is more direct, with a direct statement to the family who was 'told' they were 'going to change' and a strong emphasis on the importance of maintaining one's health. There is undoubtedly additional work inside H10 in considering the long-term implications of tracking . Within the H9 and H10 family settings, selftracking takes a different shape than in prior studies, which placed a greater emphasis on short-term or episodic health data profiling. 2,19,44 The emphasis on food to achieve longer-term health goals may reflect the participants' life stage and, consequently, the roles of providers and caregivers in these families. The participants in H9 described how tracking encounters resulted in a robust set of motives for change sustainability: My mom had a rough time when my dad left us. She's extremely protective of my sister and me […] I'm a great advocate of training and playing semi-pro soccer. I was self-tracking to maintain my fitness level, so I didn't get bored with training when it was out of season. My mom trains with me and my sister everyday now, so she's strict about our diet. I'm so proud of her and the opportunities she's offering us. For the experienced tracker in H9, interest in selftracking was initially separate from the rest of the family and contrasted with some of the cynicism in the literature in the context of an increasingly influential data culture and autonomous healthcare systems. 30,45 The response to concerns about weight demonstrates the family's health validation while making fun of the aesthetic tracking goal. The use of humour shows family closeness and pride. I believe the conversation reassured each member about their fitness level while also allowing them to briefly raise ongoing concerns about not being able to 'talk about health'. In their study, Will et al. describe the interview as a 'location for negotiating tracking as care' 25 . The interview's tone changed when f48 mentioned not discussing her health with her parents. While caring is evident here, so is intergenerational conflict over the actions of other family members. In other households, taking pride in health opened up discussion about trust in tracking: I know it might be silly to really trust an app, but I enjoy control of my health and learn new things about fitness that I can share with my family. . Home connections aided in alleviating the suspicion associated with health data surveillance. Again, the interview's digital format enabled this discussion, plus contemplation on the 'dark side' of tracking. 30 In H12, participants discussed the importance of sharing health data across generations: It has been amazing to see her light up during our walks together. She wasn't so keen to track what she was up to, saying that it was pointless, and she didn't trust the technology. Now we're sharing about our steps and her favourite is the sleep data. Though distrust of 'the technology' was discussed, wellbeing investment was crucial in abating such concerns. In reply to her granddaughter, talked about a 'renewed sense of closeness' with family. These arrangements contrast with Loe's 26 findings, whose older female participants desired greater autonomy by utilising technology's agential capacities to navigate health challenges independently of family members. Where a large proportion of Loe's participants were living alone, they did not have the opportunity to negotiate health information and support structures on a more intimate level. Far from seeing tracking data as a cause for concern, participants did not feel anxious about sharing their data and took pride in sharing their achievements. One explanation could be, in contrast to the United States with privatised healthcare, for European nations and in the UK, there is a lower prevalence of commercial organisations using tracking to incentivise commercial health plans. 24,43 Although awareness of commercial aspects of tracking was evident, sense-making was primarily linked to social structures to inform behaviour, as in H13: It's odd to be so conditioned to your health and rely on technology to tell you what to do. 'Being watched by the Gods', as they say, reminding me that I can't do anything 'bad' but at the same time I want to indulge I was overweight for a long, long, long time and I have a constant anxiety about going back to that. In H13, doing anything 'bad' might invalidate future health choices. Tracking is a practise forming part of what Nettleton and Green 5 observe as 'embodied and embedded social action,' and it is clearly demonstrated in this study in the social and material environment of the home where health and being healthy derive meaning. --- Discussion and study limitations Trackers will become more diverse, addressing different health concerns, as tracking technologies become more affordable and internet and smartphone infrastructures more widely available. Like those in this study, many more trackers are not locked into aesthetic online health communities and do not belong to any formal health movement. 22,40 The attention to the consistency of health change within these households helped temper concerns raised in other studies about how individuals are conditioned by their health data. 12 The consensus amongst participants was improved family caring and other household caregiving situations. 27 Participants repeatedly spoke about new ways to focus on maintaining health within the home, taking the focus away from performative social media sharing. 1,11 Such techniques can help explains contradictory accounts of practise, such as the need to be on social media while criticising its content. This viewpoint was discussed in the context to share and stay connected, which has become an expected part of everyday digital culture. The lives of these trackers suggest that responses to questions about health responsibility should be less individualistic and include co-tracking social practises. While public policy rhetoric emphasises the cost-effectiveness of preventative health measures for individuals, opportunities to care for loved ones in the more intimate household setting resulted in sustained positive health behaviour change. 41 More fundamentally, in outlining the possibilities for tracking practise and identifying the conditions for health change, we must go beyond simply noting that tracking is about self-monitoring and begin incorporating the structural social and material conditions. 21,28,31 The study has obtained novel findings on health behaviour as social practice and the dynamics of tracking within households, but it has limitations. All households were primarily English-speaking, potentially limiting the ability of those using their second language to engage in more organic and tangential discussions during interviews. Participants' awareness of the joint interview setting is likely to have encouraged more performative interactions and conversations, with some of the more negative aspects of tracking perhaps glossed overevident in H9 in the context of the hidden and tense set of practices Hardey around health. Relatedly, some of the experienced trackers were dominant forces during interviews, necessitating talking space for the new trackers to contribute. This was accomplished by introducing new talking points and exchanging personal tracking experiences. Further, I am curious how my experiences influenced the interviews: my personal tracking experiences made conversations more candid, and the shared nature of our reflections was described as 'reassuring' by participants and stimulated interest in the study's findings. Finally, the study reinforces the privileged characteristics of trackers living in cities with ubiquitous access to technology. --- Conclusion This study contributes to research exploring the communicative value of self-tracking within social groups. Households can teach us how tracking can open up conversations about health, further scrutinise health technologies within the home as potential instruments of control; and identify ways in which health behaviours are meaningfully constructed and sustained. The value of identifying social practice in tracking research is that it recognises combinations of behaviour and repeated performances of certain practices. The household dynamic afforded longer-term opportunities to invest in health practices for these trackers. Therefore, the true tracking is not of the health data but of the accounts of daily check-ins, of new opportunities for care and the social relationships within the household that motivated and underpinned embodied social practice. --- Contributorship: The author led the design and analysis and write up of the study. --- Declaration of Conflicting Interests: The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. --- Ethical approval: The study was approved by Durham University Business Ethics Committee . All interviews were conducted following oral consent from the participants. Informed consent: Not applicable, because this article does not contain any studies with human or animal subjects.

The purpose of this article is to examine the effect of different types of self-tracking users (trackers) on the health behaviours of others living in the same household. The study takes an international perspective, examining tracking practises from 13 households based in Europe, the United Kingdom and the United States to determine how trackers contribute to emerging cultural and social factors across life stages. The findings contribute to digital health understandings by shedding light on collective practises formed within frequently intergenerational households. The study emphasises the importance of crosscultural and intergenerational tracking research to foster collective and symbolic health engagement. The article delves into the intersection of online and offline dynamics to describe the social practice of digital health culture. It sheds new light on structural and agency issues in households sharing self-tracking experiences.

INTRODUCTION The public health problem of unwanted sexual experiences in adolescent boys and young adult men is poorly understood and has received little attention around the world. Despite the pervasive minimization and denial of such coercion, studies have found that it can have a range of negative effects on psychological and physical health and sexual function . History of USE has also been linked to higher rates of unprotected sex and other sexual risk behaviors and greater odds of having been diagnosed with a sexually transmitted infection . Evidence on the prevalence of USE in adolescent boys and young adult men is limited. In a multinational study of students enrolled in 38 universities, past-year physical coercion to have sex was reported by 2.8% of male students who had been in a heterosexual relationship in the past year; the corresponding figure for verbal coercion was 22.0% . In a sample drawn from 12 U.S. colleges, 22.2% of male participants reported some form of USE over their lifetime, with 8.3% reporting severe USE . In a survey of University of Costa Rica students, 12.8% of male students reported some form of USE before age 18 . Approximately 10.5% of men reported at least one lifetime USE occurrence in a survey of university students in Italy . Analyses based on study populations outside the educational sector in various countries have also reported variable prevalence estimates . In Chile's 2000 National Survey of Sexual Behavior, administered to a representative urban sample of adults, 1.9% of male participants responded affirmatively to the question "Have you ever been a victim of rape?" ; other forms of USE were not assessed. A critical literature review based on samples of North-American and European adult men noted several reasons for the wide range of prevalence estimates, including differences in populations studied, time frames considered, and USE definitions . Self-reports of USE are also known to be sensitive to number and phrasing of items and the context within which questions are placed in the survey . These differences across studies also have implications for examination of other aspects of USE, including risk factors, contexts, and barriers to disclosure. The literature on risk factors for USE in adolescence and young adulthood is overwhelmingly based on samples of women. Numerous studies have identified childhood sexual abuse in girls as a strong predictor of subsequent USE . Research on violence-related sequelae of CSA in boys has largely focused on associations with subsequent perpetration of violence against women , but recent studies have begun to examine links with revictimization. The multinational study of USE in university students cited above found that men with a history of CSA had elevated adjusted odds of both physically-and verbally-coerced sexual victimization over the past year; for each additional type of CSA experienced , the odds of these forms of USE were 1.48 and 1.28 times greater, respectively . A Canadian national study of adults, currently or previously in marital or cohabiting unions, found a positive association of CSA in boys with subsequent physical and psychological intimate partner victimization . Based on the National Violence Against Women Survey-a representative U.S. data set on adult men and women-another study found that among men who reported CSA, the AORs for physical and sexual victimization in adulthood were 2.5 and 5.5, respectively . Just as the sexual behaviors assessed in measures of USE in young men vary greatly across studies, the same is true for CSA ; in the studies cited above, CSA measures ranged from assessing only the most severe types of USE to assessing "unwanted sexual touching, fondling, rape, or attempted rape" . Regarding other risk factors, some studies have suggested that witnessing domestic violence in childhood may increase vulnerability to subsequent USE and poor family functioning and cohesion have been linked with heightened risk of sexual revictimization among those with a history of CSA . Mixed findings have been reported regarding the influence of socioeconomic status of the family of origin . With regard to living arrangements, college students who reside away from their parents have less supervision and family support and may, therefore, be more vulnerable . Other research has found associations between measures of consensual sexual activity and exposure to potential sexual aggressors . Urbanicity may also affect such exposure but has received little attention to date . A small number of studies have examined contexts of USE in men. Research based on a nationally representative sample of U.S. adult men found that the most common assailants were acquaintances, friends or partners-but strangers were involved in 19.5-39.4% of cases where the perpetrator was male, varying by the type of USE . A high level of concurrent substance use was found in a New Zealand community-based study of USE in men who have sex with men . Same-sex perpetrators have been found to be involved in a substantial minority of cases of USE in men . Research with women has found that underreporting of USE in surveys is often related to failure to perceive the experience as coercive or to recall the experience in response to item phrasing, and conscious decision not to report for reasons including feelings of shame ; similar factors influence nondisclosure to the police and health professionals. In men, additional barriers to disclosure include fear of being judged to be gay, and widespread conceptions of masculinity which dictate that men should be physically and mentally strong, self-reliant, and sexually assertive . Other research on barriers to disclosure has found that male rape myths-false and prejudicial attitudes and beliefs regarding sexual assault against men -operate most strongly in the case of female assailants . Adherence to such myths has been found even among professionals who provide services in response to USE. For example, a qualitative study of 30 sexual assault crisis providers in a Southeastern U.S. city found that male law enforcement officers often did not acknowledge that men could be victims; at the same time, many female crisis center workers held the view that women almost never commit sexual violence and that, given their strength and power, men are rarely victims . The present study analyzed a sample of male university students in Chile. As of 2008, 54.0% of men ages 18-23 years in the country were attending an institution of higher education . To date, no quantitative studies have examined USE in this population. The aims of this study were to examine: prevalence of and risk factors for USE since age 14, and contexts and reasons for non-disclosure of USE. In our multivariate analyses, we focused on USE before age 14 as a predictor of USE since age 14, adjusting for two other domains addressed in the survey: witnessing domestic violence in childhood and socioeconomic/ demographic variables. In ancillary analyses, we examined associations of USE since age 14 with two other forms of coercion in the same time period: physical dating violence victimization and being coerced to have sex without a condom in the context of a consensual sexual encounter. Studies with adolescent girls and young adult women in the U.S. and other countries have documented high prevalence of co-occurrence of USE and PDV ; related analyses have found a high prevalence of co-occurrence of PDV and coerced condom non-use as well as a positive association between history of PDV and fear of negotiating condom use . A study of students at 19 U.S. colleges found that substantial percentages of male and female participants reported cooccurrence of past-year sexual, physical, and psychological victimization by a dating partner . To our knowledge, ours is the first study to assess co-victimization involving coerced condom non-use in adolescent boys and young adult men. --- METHOD Participants The 2005 Survey of Student Well-Being, a closed-ended, self-administered questionnaire compiled by the lead author of this study, was administered to students attending General Education courses at a large, public university in Santiago with a socioeconomically diverse student body. Total enrollment in the 24 General Education classes was 2,451, with some students registered for more than one class. On the day of survey administration, 1,193 students were present in the 24 classes, consistent with the typical attendance rate; 970 students returned completed surveys, a response rate of 81%. Students who had completed the survey in another class were instructed not to do so again, which accounts for some of the non-response. Sixteen cases with missing data on participant's sex were eliminated, along with four cases with invalid data: two students who reported that they had not provided honest responses and two students whose internally inconsistent responses indicated that they had not taken the survey seriously. The final sample included 484 women and 466 men. The present study utilized the male sample. --- Procedure The project was approved by the university's Ethics Committee for Research on Human Subjects. Trained survey administrators explained the survey purpose and sensitive nature of the content to students, emphasizing that participation was voluntary and responses would be anonymous. Students signed and returned a consent form. They were instructed to sit one chair apart where possible and told that the first 25 minutes of the class period would be allocated to survey completion. The survey items measured USE before and since age 14, PDV, coerced condom non-use, and family background variables, including childhood witnessing of domestic violence; most were based on scales validated in the U.S. After translation into Spanish, backtranslation to English was performed to ensure accuracy; Chilean faculty and students also provided input to ensure that the translation preserved the intended meaning of the measures. --- Measures USE since age 14-The section in the questionnaire on USE began with a paragraph that established a context for recalling a range of such experiences, including incidents in which the participant may have been "asleep, drunk, or otherwise incapacitated," and where "sex" was defined as vaginal, oral or anal sex. Participants were then asked to respond "yes" or "no" to the following items regarding USE since age 14: Someone tried to make me have sex by using threats, arguments or physical force, but this did not happen; Someone forced me to have sex using physical force; Someone forced me to have sex using threats or other verbal pressures; Someone had sex with me after I had been drinking or using drugs, and I was not in a condition to be able to stop what was happening; Aside from the types of sexual contact already mentioned, have you experienced any unwanted sexual experiences, such as forced kissing or grabbing? Items 2 and 3 above were adapted from the Conflict Tactics Scale-2 . Items 1 and 4 were included following the Sexual Experiences Survey ; the wording was adapted for consistency with Items 2 and 3. An affirmative response to Item 2, the most physically severe form of USE, was coded as physically-forced sex. Affirmative responses to Items 3 and 4 were coded, respectively, as verbally-forced sex and forced sex while intoxicated; an affirmative response to Item 1 was coded as attempted forced sex through physical or verbal coercion . For use in the multivariate analyses, we constructed a summary dependent variable indicating the most severe form of USE since age 14, if any, reported by the participant. The three mutually exclusive categories were: forced sex/ attempts; less severe forms of USE ; and no USE. Our definition of the most severe form of USE since age 14 must be distinguished from the participants' own assessment of the most severe incident since age 14, discussed below in the section on contexts and disclosure. USE before age 14-The main independent variable was operationalized as equal to 1 if the participant responded affirmatively to at least one of the following items: "Before age 14, did someone ever make you have sex against your will?" and "Before age 14, did you ever have any other form of unwanted sexual experience, such as forced kisses, grabbing, etc.?" Related to this measure, the survey also contained an item on the relationship of the perpetrator to the participant in the incident before age 14 considered most severe by the participant. Control variables-We used three dummy variables to indicate frequency of childhood witnessing of violence between parents/guardians: "often," "several times" and "rarely" . A continuous variable measuring the participant's age at the time of survey administration was used to adjust for length of exposure to USE risk. Parental education was coded as 1 if the highest educational level attained by the participant's parents was 12 years of regular schooling or less or incomplete advanced technical schooling or less; we refer to this category as "low parental education." An urbanicity variable was used to indicate that the participant lived in Santiago or another large city at age 14, and a non-intact family of origin variable to indicate that he did not live with both parents at age 14. Other variables indicated whether the participant had primarily lived outside the parental home since entering college, and whether he had ever had consensual vaginal or anal sex. Contexts of violence and disclosure-For participants who reported any USE since age 14, the survey included items regarding contexts of the incident considered most severe by the participant; these items addressed concurrent substance use, incident location, and perpetrator-participant relationship. Information was also collected on whether the participant told anyone about the incident and on barriers to reporting to the police. Sex of perpetrators-Participants who reported any lifetime USE were asked a question on the sex of the perpetrators. Co-victimization-The first measure used in co-victimization analyses was a variable for PDV, based on items adapted from a scale used by Foshee . These items were addressed to participants who indicated that they had ever gone out on a date or had a romantic relationship since age 14. Prior to these items, the survey instrument included instructions that created a context for recalling incidents of unwanted physical violence. The PDV variable was coded as 1 if the participant reported that a date/partner had ever: "scratched or slapped me," "pushed, grabbed, or shoved me," "slammed me or held me against the wall," "kicked or bit me," "hit me with a fist," "hit me with something hard," "hit me repeatedly," "tried to choke me," "burned me," and/or "assaulted me with a knife or gun." The second measure used in co-victimization analyses, adapted from an item in a scale developed by Straus et al. , equals 1 if the participant responded affirmatively to the question: "Since age 14, has it ever happened that your boyfriend/girlfriend or dating partner made you have sex without a condom, when you wanted to use a condom?" Data Analysis-After deleting 50 cases with missing data on USE before and/or since age 14, the study sample consisted of 416 men. We generated descriptive statistics for the dependent and independent variables, as well as a frequency distribution for the perpetratorparticipant relationship in the incident before age 14 considered most severe by the participant. Generalized ordered logit models were then estimated to examine risk factors for USE since age 14, using GOLOGIT2 in STATA version 9.2 . This procedure utilizes information regarding the order of the three categories and allows the proportional odds assumption to be relaxed for variables that fail to meet it. We estimated the bivariate relationship between USE before and since age 14 and two multivariate models. The first model adjusted for witnessing domestic violence before age 14 and socioeconomic/demographic factors: age, parental education, urbanicity, and nonintact family of origin. The second model added variables regarding two choices made by the participant: whether he had lived away from his parents while attending college and whether he had ever had consensual sex. Given the potential for extended abuse by the same person , we also re-estimated the second model excluding the 8 cases in which the perpetrator in the incident before age 14 considered most severe by the participant was identified as a family member or partner of a family member. We then generated descriptive statistics for contexts of the incident since age 14 viewed by the participant as most severe, as well as barriers to disclosure. Finally, we conducted crosstabulation analyses to examine patterns of joint occurrence since age 14 of USE with: PDV and coerced condom non-use. --- RESULTS --- Sample Descriptive Statistics The participants ranged in age from 17 to 30 years, with a median of 20 years. Approximately 80.3% lived in Santiago or another large urban area at age 14. A crosstabulation of urbanicity and living arrangements showed a strong association: 90.7% of the participants who lived in an urban area at age 14 resided in the parental home while attending college . Other descriptive statistics are shown in Table 1. Approximately 9.4% of participants reported USE before age 14; the perpetrators in the incidents viewed as most severe by the participants were most commonly a friend and a family member or partner of family member . Other perpetrators were a boyfriend/girlfriend , sexual partner , classmate , teacher , stranger , and "other adult" ; the remaining cases correspond to no recall and no response . --- Prevalence of USE Since Age 14 Panel A in Table 2 shows the percentage of participants who responded affirmatively to each USE item; some participants reported more than one form of USE. Approximately 77.1% of incidents of forced sex since age 14 occurred when the participant was under the influence of alcohol or other drugs, unable to stop what was happening. Panel B classifies participants by the most severe form of USE since age 14. Overall, 20.4% of the sample reported some form of USE in this period. The most severe type was physically-forced sex for 0.2% of the sample and forced sex through verbal coercion or while intoxicated for 10.1%. The dependent variable used in the multivariate models was based on the mutually exclusive categories in Panel B: it equals 3 , 2 or 1 . --- Risk Factors Generalized ordered logit regression results are shown in Table 3. Brant tests showed that only the urbanicity variable violated the proportional odds assumption ; the corresponding odds ratios were therefore allowed to vary across categories. The bivariate model shows that USE before age 14 was associated with 4.84 times higher odds of USE since age 14 . The AOR increased when controls for family background and living arrangements and consensual sexual activity were added, but pairwise comparisons showed no significant differences between the underlying coefficients. The perpetrator of the most severe incident in childhood was a family member or partner of a family member in 8 cases . When we re-estimated Model 2 excluding these cases , the AOR decreased but remained large and statistically significant . Regarding the control variables, Model 1 shows that witnessing domestic violence "several times" in childhood was associated in the predicted direction with odds of USE since age 14 but the results did not reach statistical significance. The odds of USE since age 14 were higher for those who grew up in a non-intact family . Urbanicity was associated with substantially lower odds of USE, particularly forced sex or attempts . Model 2 shows that the odds of USE since age 14 were positively associated with having initiated consensual sex . The association with residence away from the parental home was positive but not significant. Given the multicollinearity between urbanicity and college living arrangements noted earlier, we estimated another regression including all variables in Model 2 except urbanicity. In this regression, the AOR associated with living away from parents was marginally significant . --- Most Severe Incident Since Age 14: Contexts and Disclosure Participants who reported USE since age 14 were asked questions about the contexts and disclosure of the incident since age 14 they viewed as most severe; the response rate for these items was approximately 80.0%. The perpetrator was most commonly identified as a friend, other student, or acquaintance . Other common assailants were boyfriend/ girlfriend or ex-boyfriend/ex-girlfriend and a date . The remaining cases were reported to have involved strangers , family members and teachers . The most commonly reported locations were a party and the perpetrator or victim's home . Consumption of alcohol and/or other drugs by the victim only, perpetrator only, or both, was involved in 8.7%, 11.6%, and 43.5% of cases, respectively. Among participants who indicated USE since age 14, 74.3% told someone about the incident; 65.7% told a friend, 2.9% told a psychologist or social worker, and none told a physician. None of the incidents of forced sex or attempts were reported to the police; the most frequently-endorsed reason for not doing so was "I did not think that what happened was sufficiently serious, or a crime" . Other salient reasons were "I wasn't sure that the person who did this really wanted to hurt me" ; "I felt ashamed" ; "fear of revenge from the person who did this" , and "if I told the police, they would not respond" . --- Sex of Perpetrators Before and/or Since Age 14 Among participants who reported any lifetime USE , 68.0% indicated that the perpetrators had been "women only"; the other response options were "women and men" and "men only" . The response rate for this survey item was 72.2%. --- Co-Victimization Since Age 14 Table 4 shows findings regarding co-victimization, i.e., the joint occurrence since age 14 of USE with PDV; and coerced condom non-use . The percentage of participants reporting PDV was 56.3% among those for whom forced sex/attempts was the most severe form of USE since age 14; 46.9% among those for whom the most severe form was less serious; and 33.2% among those who reported no USE . The percentage of participants reporting coerced condom non-use was 30.2% among those for whom forced sex/attempts was the most severe form of USE since age 14; 23.1% among those for whom the most severe form was less serious; and 12.6% among those who reported no USE . --- DISCUSSION --- Main Findings and Implications Prevalence of USE since age 14-In our sample of male students enrolled in General Education courses at a large public university in Chile, we found that approximately onefifth of the participants reported some form of USE since age 14. With regard to rape, the legal definition in Chile is vaginal, anal, or oral penetration of a person over age 14 by force or threats, or while the victim is intoxicated or otherwise incapacitated. Penetration of someone 14 years of age or younger is defined as rape even if the experience was "consensual." As a first approximation, our analysis suggests a forced sex prevalence of 0.2% based on a narrow definition limited to physical force and a forced sex prevalence of 10.3% if verbally-coerced sex and coerced sex while intoxicated are included. However, our survey items did not differentiate between instances of coercion where men were penetrated vs. where they performed a penetrative act that they perceived as coerced; these latter instances, while potentially distressing and harmful, do not meet the Chilean legal definition of rape. Risk factors-We found that 9.4% of participants reported USE before age 14. This prevalence estimate was consistent with findings in a review of studies conducted in 21 countries at various stages of economic development: prevalence of CSA reported by men ranged from 0 to 60%, with most studies providing estimates below 10% . In our sample, USE before age 14 was associated with 5.52 and 6.38 greater adjusted odds of USE since age 14 in Models 1 and 2, respectively. A meta-analytic review of CSA and revictimization in women found that studies that used the most restrictive CSA definitions reported the largest effect sizes . To the extent that a similar pattern may hold for men, our study-based on a broad measure of USE before age 14 that included relatively "minor" forms of coercion-likely resulted in a weaker estimated association than would have been obtained with a more restrictive definition including only more physically severe forms of abuse. It is thus particularly noteworthy that we found the adjusted odds of USE since age 14 to be approximately six times greater for participants who reported USE before age 14 than for those who did not. As noted earlier, an AOR estimate of 5.5-a similar magnitude-was reported in a national U.S. study of adult men , using a CSA measure that was limited to the most severe forms of abuse; recent research based on data from other countries has also found evidence of a strong association in men between CSA and subsequent USE and intimate partner victimization . Our results thus add to a growing international literature that stresses the importance of strengthening public health efforts to prevent, identify, and respond to CSA. With regard to other variables included in our analysis, growing up in an urban area and in an intact family were associated with lower odds of reporting USE since age 14, and there was some evidence suggestive of witnessing domestic violence in childhood as a risk factor. Consistent with Chilean norms, we found that only one-fifth of participants had primarily lived away from the parental home while pursuing college studies; the study findings suggest that these students may have elevated odds of USE, meriting special attention in prevention efforts. Participants who had initiated consensual sex were also found to have higher odds. It should be noted that the coefficients associated with choices on place of residence and consensual sex may partly reflect unobserved characteristics of the participants that influence vulnerability to USE. Most severe incident since age 14: contexts and disclosure-Our finding that substance use by the victim, perpetrator, or both was involved in almost two-thirds of the incidents considered by the participant to have been most severe underscores the importance of incorporating drug and alcohol education programs in interventions for sexual assault prevention/risk reduction and vice-versa. Also relevant to the development of interventions are our findings that the assailant was identified as a friend/acquaintance or date/partner in 50.7% and 34.3% of such incidents, respectively. None of the participants who indicated experience of forced sex or attempts notified the police, in accordance with earlier studies that found USE in men to be a notably underreported crime . Also consistent with earlier study findings , 14.3% of these participants cited "shame" as a reason for not reporting the USE. Almost two-thirds indicated that they did not report the most severe incident since age 14 to the police because they did not think that what happened was sufficiently serious or a crime or that the person who did it had not meant to hurt them. Such attitudes, minimizing the reality or significance of men's USE, may also contribute to reducing men's seeking of health care or psychological support for these experiences. In this study, only 2.9% of participants who reported USE since age 14 told a mental health professional about the most severe incident and none contacted a physician. Friends were by far the most common confidants, suggesting the importance of bystander education programs which aim to teach participants how to identify signs of risk in community members, intervene where feasible, and be an effective ally for survivors . Efforts to design prevention programs that dispel male rape myth beliefs and promote health-supportive gender role attitudes among the general population and service providers are also important items in the agenda for public health practice. Such work is particularly needed in socially conservative societies such as that of Chile; this conservatism is evident in a range of Chilean study findings. For example, in the 2000 national survey mentioned earlier, only 3.7% of male participants reported "approving" of male homosexuality . Another Chilean national survey of adults in 2001 found substantial adherence to traditional gender roles, with men, less-educated participants, and older participants holding the most traditional views . Laws and programs have both reflected and reinforced this sociocultural environment, e.g., divorce was legalized in 2004, making Chile the last Western country to do so, and the first workplace equal pay law was passed in 2009. A recent national Healthy Universities initiative in Chile, designed to promote healthy behaviors in university students and developed in collaboration with the Chilean Ministry of Health, made no mention of sexual assault or dating violence . To our knowledge, there are presently no established campus programs for sexual assault prevention in Chile, and there are no commonly-understood Spanish-language terms for "date rape" or "acquaintance rape." We theorize that conservative reluctance to publicly address "sexuality" in young people extends to reluctance to discuss and address "sexual" assault. Sex of Perpetrators-Approximately 32.0% of study participants who reported any lifetime USE indicated that some or all of the perpetrators were men. A similar result was found in a study of university students in Italy, where one-third of lifetime USE reported by men involved male perpetrators . Focusing on the complement of this statistic, approximately two-thirds of participants who reported any lifetime USE indicated female perpetrators only. Related research based on two community samples of young heterosexual men in Germany found that 25.1-30.1% of participants had experienced female-perpetrated USE and that most men described these incidents as "moderately upsetting" ; as emphasized by the authors of this study, it is unclear whether these findings reflect a genuine lack of strong adverse effects, or denial/ minimization. A possible contributing factor is the inclusion of relatively "minor" incidents, such as forced kisses, in some USE definitions . In addition, psychological impacts of coercion perpetrated by women may be mitigated by the fact that sexual activity with a woman, even under circumstances of coercion, is congruent with the stereotypical male role, unlike sexual activity with a man . Co-victimization since age 14-In this study, participants who reported forced sex or attempts since age 14 were significantly more likely than those who did not to also report PDV and coerced condom non-use in this period, consistent with prior study findings for adolescent girls and young adult women . Although the survey instrument did not assess specific means used to coerce the participant to not use a condom within the context of a voluntary encounter, these may have included verbal pressure to not use a condom, outright refusal to have sex with a condom, and /or some physical demonstration of unwillingness to use a condom. Experiences of co-victimization may partly reflect background factors such as CSA that independently affect the risk of each form of subsequent victimization; in addition, experiencing one form of victimization during adolescence and young adulthood may augment vulnerability to another. Our findings suggest that these various forms of violence should be addressed jointly in prevention programs and that healthcare providers interacting with young men who report any of these forms of violence should inquire about the others. --- Limitations and Directions for Future Research The study sample included students enrolled in all educational programs of the university, but was not a representative sample; the findings thus cannot be generalized to the full student body. USE before and since age 14 were likely underreported due to factors including shame, denial, recall error, and failure to interpret coercion or abuse as such. Our items regarding USE before age 14 did not inquire about the age difference between the perpetrator and child, as do some CSA measures ; our measure, therefore, likely captured some cases of peer-level sexual interaction, which may have fewer long-term sequelae than those involving older perpetrators with substantially greater power . Hence, our estimate of the association between childhood USE and USE since age 14 may be biased downward. In addition-as is the case for most previous studies in the field-our survey did not collect information on participants' sexual orientation or sex of the perpetrator in the most severe incident since age 14, limiting our ability to interpret the findings; doing so required items that were beyond what was culturally acceptable for an initial study in a socially conservative setting. In a similar effort toward contextual sensitivity, our survey assessed USE in men with a small set of general questions which were the same as those used for female participants. Men's responses must be interpreted as reflecting their perceptions when presented with such items; the lack of behavioral specificity regarding whether a penetrative act was unwillingly performed vs. sustained by the participant is a limitation of our study. Although this limitation is widespread among earlier studies in the literature , it has received little attention. Further qualitative research should aim to gain a better understanding of men's perceptions of sexually coercive situations with male and female perpetrators; these efforts will help guide the development of sexual assault risk reduction programs for men. It would also be desirable to conduct further quantitative inquiry using the revised SES , which contains items that were developed with behavior-specific wording to elicit information on a range of unwanted sexual activities; this will make it possible to base men's rape prevalence estimates with more specificity on acts that involve sustaining forced penetration, leaving less leeway for men's individual perceptions of what constitutes "forced sex." Overall, the findings of this study underscore the importance of directing additional public health attention to USE in adolescent boys and young adult men in Chile and other countries. They also point to a need for further research on the joint occurrence of PDV and USE and resultant HIV/STI risk for young men, with samples of heterosexually active men and MSM. Note. We imputed the modal category for cases with missing values on the control variables. The variables on consensual sex and witnessing domestic violence had 19 and 20 cases with missing data, respectively. We included dummy variables for missing data on these two variables in preliminary regressions; they were insignificant and dropped from analyses. Three or fewer cases were imputed for the other control variables. Note. The sample for Panel A is N = 384, obtained after eliminating from the base sample 32 cases with missing data on PDV. The sample for Panel B is N = 267, obtained after deleting from the base sample 148 cases corresponding to participants who indicated never having had consensual sex and one case with missing data on coerced condom non-use.

The public health problem of unwanted sexual experiences (USE) in male youths has received little attention. In this study, we examined prevalence of USE, risk factors, contexts, and barriers to disclosure with data from a quantitative survey of students enrolled in General Education courses at a public university in Chile. This study focused on the male sample (N = 466). Approximately 20.4% of participants reported some form of USE since age 14. Forced sex through physical coercion, forced sex through verbal coercion or while intoxicated, attempted forced sex, and less severe forms of USE were reported by 0.2%, 10.1%, 1.4%, and 8.7% of participants, respectively. USE before age 14 was reported by 9.4% of participants and was a significant predictor of USE since age 14 (AOR 6.38, 95% CI 3.22-12.65, p < .01). The perpetrator of USE since age 14 was most commonly identified as a date/partner or friend/ acquaintance; other findings on contexts and barriers to disclosure were also generally consistent with previous results in the literature. In addition, we found substantial co-occurrence of USE since age 14 with two other forms of coercion: physical dating violence victimization and coerced condom non-use. The study findings indicate a need for further attention to these public health problems and have implications for the development of violence and HIV/STI prevention programs for adolescent boys and young adult men in Chile and elsewhere.

Introduction: non-coital practices as a 'missing middle' in research on young people's sexual behaviour In the context of youth transitions, 'losing your virginity'1 remains a significant marker in ideas about becoming an adult. For many young men, 'virginity loss' is a key moment in both personal and public understandings about the transition to manhood . Among young women, the anticipation and experience of first sex is also significant in narratives of young femininities . However, while the symbolic importance of 'losing your virginity' has been described in many settings , we know less about the significance of other sexual activities which may or may not form part of a young person's sexual trajectory. 2 In the health literature on young people's sexual behaviour, although studies have tended to be preoccupied with vaginal intercourse , researchers are increasingly examining a wider range of sexual practices that young people commonly engage in. As part of this, there is growing interest in the age and order in which various practices are initiated, with studies attempting to classify particular sexual trajectories . We know from survey data that the vast majority of young people have non-coital sexual experiences before vaginal intercourse , yet the meaning of such experiences are something of a 'missing middle' in our understanding of sexual transitions. One commonly suggested explanation for non-coital practices preceding first vaginal intercourse is that some young people substitute certain acts for coitus as a way of 'maintaining their virginity'. Yet the evidence, which mainly comes from studies in the US, is equivocal: for example, while anal intercourse sometimes appears to be used as a temporary substitute for vaginal intercourse during menstruation , evidence on the timing, spacing and order in which different sexual activities are initiated indicates first anal intercourse rarely precedes first vaginal intercourse, and is not widely practiced as a more long-standing way to 'maintain virginity' . Others have suggested that young people choose to engage in non-coital sexual activities, such as oral sex, before vaginal intercourse because they see them as less 'risky' , but as little is known about the meanings non-coital sexual practices have for young people it is not clear to what extent this is accurate. In this paper, we draw on our qualitative investigation of young people's expectations about 'normal' sexual trajectories. We examine young people's accounts about which sexual practices are considered typical, and their expectations of the order in which different sexual activities first occur and why. By using the word 'normal' we do not imply that particular practices, experiences or partnerships are 'abnormal'. Rather, we explore dominant expectations about non-coital sex -what the young people we spoke to considered to be 'typical' or 'normal'. As we discuss later, there was a strong heterosexual assumption within our sample, with participants assuming that practices would generally occur between men and women. By focusing on young people's talk about 'normal' sexual development, this paper addresses the theme of this special issue -ordinariness and 'the missing middle of youth' -in three senses. First, we examine non-coital experiences, which receive less attention than vaginal intercourse in investigation of sexual transitions. Second, we examine sexual experiences that young people consider 'ordinary', rather than specifically focusing on those at 'the margins'. Commentators have highlighted a tendency in sexualities research to focus on 'sexual others', defined in relation to dominant discourses . By examining non-normative sexualities, many studies continue to contribute towards a more nuanced understanding of the diversity of young a/sexualities . In this paper, however, our explicit focus is on ideas about 'majority' experience -in other words, 'the middle'. Third, in previous studies exploring dominant sexual discourses, the focus has often been on the gendered dynamics of relationships between men and women, sometimes leaving the actual practices of sex implicit and ambiguous: "sex itself seems to be increasingly absent" . While some qualitative studies have explored the meaning of specific non-coital sexual practices for certain groups of young people , to our knowledge there are no recent studies directly exploring the meaning and significance of a fuller range of sexual activities that young people identify as typical, and the relationship between such practices. This paper aims to complement a broader discussion about 'ordinariness' and youth transitions by contributing qualitative data about a wider range of common sexual practices than usually investigated. These in-depth accounts also allow us to explore some theoretical claims about the nature of contemporary sexual interactions. --- Shifting norms? Young people, gender and normative heterosexuality In the context of considerable social change in intimate relationships in late-modern societies, some theorists and researchers have argued that contemporary sexual life is characterised by greater 'fluidity', with more possibilities to live and love outside the restrictions of normative heterosexuality. Roseneil , for example, has highlighted a number of 'queer tendencies' characterising the shifting organisation of sexuality, arguing that these are destabilising the hetero/homosexual binary. As a result, some have suggested we might be moving towards a 'post-gay' era , where for young people today, perhaps especially young women , sexual identity categories are becoming less relevant than in the past. The extent to which we are seeing a 'queering of intimate life', has been questioned, however, with some arguing that, notwithstanding a shift towards liberal discourses of diversity, equality and democracy within personal relationships, sexual identities continue to 'matter' , and the institution of heterosexuality continues to be taken for granted as the normative form of sexuality in much of everyday life . That is not to say the boundaries of normative heterosexuality are static, however, and sociologists continue to document and analyse the ways in which these evolving boundaries are regulated through everyday practices and discourse. With respect to young people, a considerable body of work has explored how heterosexualities are constructed, prioritised, reworked and resisted in different settings, including families , peer groups , and schools . The relationship between heterosexualities and gender hierarchies has been key to these analyses, with identities conceptualised as fluid, contested and formed through discourse. In one influential study based on interviews with young men and women in the late eighties and early nineties, Janet Holland and colleagues developed the concept of the 'male-in-the-head' to explain the marked gender inequalities in young people's accounts of their sexual interactions and relationships. They highlight the asymmetry of heterosexuality in prioritising men's pleasure and desires, arguing that young women also contribute to the construction of 'heterosexuality-as-masculinity', through shared definitions of penetrative intercourse as 'proper sex', and the regulation of normative femininity. Twenty years on, the concept of the 'male-in-the-head' continues to inform sociological analyses of sexual encounters between young men and women, even as "the social and cultural context in which young people construct their adulthood and sexuality is perceived as changing" . Commenting on shifts in the social landscape since their original fieldwork, Holland and Thomson highlight increasing anxieties around the sexualisation of culture, and moral panic surrounding sexualised hyper-feminine identities. In the context of contemporary expectations for young women to perform as agentic sexual subjects, Renold and Ringrose use the concept of 'schizoid subjectivities' to describe how girls negotiate 'multiple pushes and pulls' between, for example, victim and empowerment or sexual innocence and excess knowing. In their analysis, girls' sexual transitions are conceptualised as 'multiple, liminal, reversible, rather than one progressive state to another ' . In this paper, we ask how might young people's accounts of non-coital sex contribute to our understanding of discourses surrounding contemporary sexual transitions? And what are the social norms shaping ideas about sexual practice for teenagers growing up today? --- The sixteen18 project We conducted a qualitative mixed methods study to explore the range, sequence and meaning of sexual practices among a diverse sample of 130 young people aged 16-18. The study was approved by the London School of Hygiene and Tropical Medicine ethics committee and we obtained written consent from all participants. Fieldwork began in 2010 in three socially and geographically contrasting sites in England: London, a medium-sized northern, industrial city and a rural area in the south west. To get a sense of how different sexual practices were discussed socially, we conducted nine group discussions, with three groups of six to nine participants in each of three sites: one all-men, one allwomen and one mixed-sex . For the first groups in London, we recruited friendship pairs to try to increase participants' willingness to contribute to discussion. Some pairs seemed understandably reluctant to discuss their thoughts on sexual practices with other unknown pairs, and so in the other fieldsites we recruited friendship groups. The discussions lasted between 60-90 minutes, and were conducted in a variety of settings, including a university teaching room , a school classroom , a private room in a cafe and a private room near a health centre . We asked young people to list all the sexual practices they had heard of, and then discuss which they thought were typical for 16-18 year-olds, when they would expect them to occur and with whom. These discussions were valuable in giving us a sense of norms around initial sexual experiences, which we could then explore in individual interviews where, away from the peer group setting, we could see how participants articulated, reworked or resisted these norms in narrating their own, predictably more diverse, experiences. Next, we conducted 71 face-to-face semi-structured interviews with 16-18 year olds , with follow-up interviews one year later . Because our aim was to include young people from different social backgrounds, we recruited participants from a range of settings, including: schools/colleges , youth work services targeting young people not in education or training , youth organisations , a supported housing project for young people living independently from their families and informal networks . We also used snowball sampling and, in the rural south west, we approached people directly in a town centre . We did not sample for particular types of sexual experience . Instead we highlighted in our information leaflet and our conversations with potential interviewees that we were keen to speak to any young person, whatever their experiences. Although participants varied in terms of the range of activities they had experienced, and the number and nature of their sexual partnerships , the majority reported opposite-sex partners only. The majority of our interviewees were living with their parent/s , one with other family, and five were living independently. Most were primarily studying full or part-time , with two working, one in an apprenticeship and eight unemployed or looking for work. In the first interviews, we explored participants' sexual experiences, including the sequence, timing, relationship, and situational context of events; perceptions of friends' and peers' sexual activity; and future sexual and relationship aspirations. The challenges of finding acceptable language to discuss sexual behaviour within a research encounter are well known, with debate about the use of common vernacular or technical terms . In this study, as in others , participants' used 'sex' to refer to vaginal intercourse. However, many said it was 'awkward' or 'difficult' finding terms to talk about non-coital practices. Where possible, we waited for interviewees to introduce their own terms for practices, and asked them to define what they meant. We also took particular care not to assume the sex of any partner before the interviewee had identified them as a man or woman. However, the assumption among participants was that sexual experiences were between opposite-sex partners, unless otherwise stated. In the second interviews we asked participants whether they had ever had a same-sex experience, and how common they thought this was among people their age. Individual interviews lasted 50-90 minutes. Our approach to data collection and analysis was informed by grounded theory . We audio-recorded and transcribed interviews verbatim, and entered transcripts and field-notes into NVivo software to support data analysis. We 'open-coded' transcripts from the first interviews to identify key themes, concepts and processes , then discussed initial themes, choosing some for further exploration in the second interviews. As well as exploring emerging themes in more depth, the second interviews aimed to explore continuity and change in young people's lives, both generally , and in terms of their sexual experiences and attitudes. The topic guide for the second interviews was tailored to individual participants so we could also follow up themes particular to them. We used 'memos' to develop our analysis, making constant comparisons between individuals' experiences and identifying 'deviant cases' to challenge interpretations. --- Normative expectations of initial sexual experiences Expectations of a 'normal order' The young people we spoke to routinely identified five genital sexual practices as typical among their age group: fingering, 'hand jobs', 'blow jobs', 'licking out' and 'sex' 3 . Both young men and women expected these sexual practices to be experienced incrementally in a series of 'bases', 'stages' or 'steps', with non-coital practices often described as 'building', 'working' or 'leading' up to vaginal intercourse, which was widely constructed as the most significant practice: I generally assume that people sort of [...] they will sort of go, kind of build up, going, mainly you know, do things with their hands, then maybe develop into things with their mouths but because, you know, vaginal sex is sort of the kind of most intimate thing, that is usually something I would expect people to leave till last. Participants appeared to perceive a 'normal order' to sexual development, in which hand-genital practices would be experienced before oral-genital practices, which in turn would be experienced before 'losing your virginity'. This order was described as rigid: "I think the order is actually set though isn't it?" , and: "I just kinda think it's an order which has just been around since, because sex is kind of like seen to be the biggest thing, and it is really" . Within talk about this order being 'set' or 'fixed', some young women described an expectation from male partners that once a practice had been experienced once, it would be done again; for example, this young woman described being pressured by a boyfriend to give him a 'blow job' after he found out that she had done this with another man previously: So yeah, I did a blow job twice but the second one was because I told the guy I had done [...] The second one, the guy was out to move on, I've done it before so do it again, do it to me and then I just felt obliged to do it then, you know, just to please him and stuff. This sense of obligation to do a sexual act because it has been done before, which was also present in other women's accounts, illustrates the common characterisation among our interviewees of sexual development as progressive and irreversible. Although young people rarely reported discussing non-coital practices in school sex education, they often referred to this expected pattern of sexual activities as something they had learned or been taught. As in other studies , we found peer groups were a key site for production and regulation of normative sexualities , with the idea that there was a normal or 'correct' -and in turn an 'incorrect' -way to move through different sexual activities, produced between sexual partners and friends through discussion about 'how far you've gone'. As seen in Pippa's extract below, this meant that the ordering of sexual experiences formed one more component of young people's policing of 'appropriate' sexualities: The first time you actually do it ever, like there's always steps. Like you wouldn't just jump straight in to sex and not do anything else. Like we'd hear about people that did and we'd be like, 'what, they just like had sex and not done anything else?' So like there was the order, like first do oral sex, then sex. In line with expectations that non-coital practices would precede 'having sex', most of our depth interviewees had experienced some form of partnered genital contact before first vaginal intercourse. However, a significant minority of our sample reported 'losing their virginity' during their first partnered experience. Most of these encounters were described as occurring when they were between 12 and 15 years old, and being pressurised or unwanted, unexpected, unprotected, and often with sexual partners with whom the participant was not in a relationship. In accounts of 'having sex' before non-coital practices, young people stressed that their experience was atypical, referring to the so-called 'normal order' as their benchmark. For example, one young man recalled his first sexual experience at a party aged 13 with an older girl: " While young women's regret about the timing and circumstances of first sex was discussed by both sexes in group and individual interviews , the possibility that young men might feel they had sex 'too soon' was only discussed in the individual interviews, suggesting that for men, a dominant discourse of eagerness to have sex constrains the ways in which non-normative sexual trajectories can be articulated. --- Same-sex experiences Many young people said it was relatively commonplace for girls to kiss each other, and several of the young women reported having done so, although this was often qualified as being 'for dares' in front of friends when drunk, suggesting that it was sometimes not seen as a 'real' sexual experience. A small minority reported same-sex genital contact, although again some questioned whether this 'counted' as a 'proper experience'. For example, Alicia , who was with the same boyfriend in both her interviews, talked about her first sexual experience, which involved 'hands down knickers' and both giving and receiving oral sex with a woman. Although Alicia told friends she had 'had sex' with a girl, she described feeling unclear whether the experience 'counted' as losing her virginity: "that's what we were talking about when we were drunk. Whereas a woman having had a same-sex experience did not seem to make her 'lesbian', for young men, there was little sense of any separation of experience from identity. For instance, while many of our interviewees talked about isolated incidents of boys 'coming out' to their friends or at school, young men were not expected to experience any same-sex sexual contact unless they were 'gay' . This distinction was reflected in Shane's second interview: Shane contrasts the perceived hetero/homo binary for young men , with the broader possibilities for young women to 'try', and explains this difference in negative terms -by constructing young women as not 'knowing themselves'. Um Among our interviewees, then, non-coital experiences were largely imagined in terms of heterosexual norms, with ideas about the appropriate ordering of different sexual activities rigidly constructed and policed through discourse. Although young people's actual sexual experiences were more diverse than those they considered 'normal', the script of normative sexual development shaped the way in which they narrated their own experiences. In the next section we examine how young people's talk about the role of non-coital practices in sexual development reveal clear gender differences in the significance of those practices for young men and women. Why are non-coital practices expected to precede 'virginity loss'? When reflecting on the 'normal order' of sexual 'firsts', individuals often stressed that their personal experiences had not been planned: "you know what they say, like one thing leads to another? It just kinda happens" . Yet, as described above, our interviewees' accounts revealed a clear expectation of 'normal' sexual development, with certain practices experienced step-by-step in preparation for 'having sex'. Young people explained why they expected non-coital practices to precede 'losing their virginity', by calling on ideas that non-coital practices help develop and demonstrate sexual skill, prepare girls for vaginal intercourse, enable learning about partnered sexual pleasure, and are part of developing intimacy in a relationship. --- Developing and demonstrating sexual skill Many young people, particularly men, talked about 'getting used to' or 'practising' preliminary activities before 'moving on' to sex. Engaging in non-coital practices provided an opportunity to achieve familiarity with particular activities, and to develop skills required to be a proficient sexual partner. Such accounts were generally characterised by a sense of building a portfolio of sexual skills that could be applied with any partner, rather than being grounded within a specific relationship, and were more common among those who had experienced different sexual 'firsts' with different people, rather than within one longer-term girlfriend/boyfriend relationship. For young men, non-coital sex was a chance to gain 'first hand' experience of opposite-sex genitalia. Many men described vulvas/vaginas as 'disgusting' or 'dirty', and yet still wished to encounter them. This participant, for instance, had already been 'tossed off' and 'sucked off' on previous occasions by different girls: I hadn't fingered anyone before and I'd always wanted to. I'd rather finger someone than have anything done to me at the time cos I wanted to, I'd never experienced a girl's like, um, like area or anything like that so I really wanted to know what it was like and feel it. Another young man, who had experienced different sexual practices with a relatively large number of women, reflected on his first sexual experience, which was with a girlfriend when he was 13 yearsold: ... In this extract, this young man describes an etiquette in which digital penetration is 'aggressive' if sudden, and must be negotiated following 'rubbing and caressing'. For Rabi, this initial non-coital experience appeared to be significant both in terms of developing his 'technique', and becoming competent in judging his partner's pleasure . Non-coital practices were also described as a way in which young men could demonstrate their 'skill', as well as developing it, to encourage women to have intercourse with them. For example, when asked whether certain 'common' practices were more enjoyable than others, the following exchange occurred in a mixed-sex discussion group: Woman 1: They all give you different feelings but for me I think it's sex really. Woman 2: Yes, sex. Woman This extract might be read as an illustration of the competing discourses young women navigate in their sexual 'becomings' : despite the final statement assertively positioning women as 'in control', the notion that men demonstrate sexual skill in order to 'advance' to the pinnacle of sexual relations echoes conventional discourses about men as sexual initiators, and of women resisting vaginal intercourse . --- 'Preparing' girls for vaginal intercourse In line with the conventional discourse of men always being ready for sex, our interviewees did not talk about the need for boys' bodies to be prepared for having intercourse. By contrast, accounts of 'fingering' revealed a clear assumption that vaginas need to be physically 'prepared' for penetration by a penis: Woman 1: You have to get fingered before you have sex you know. Woman 2: Loosen. Man 1: Practice. --- Int: So that has to happen does it? Woman 1: It doesn't have to but it helps. Woman 3: It's an aid. Man 2: It can happen like days before. Woman 1: Nah I don't mean like a minute before. I mean like before you think about having sex like. --- Woman 2: That's the first step, yes. The most common explanation for the need for fingering was to reduce pain for the woman when it came to penetration by a penis, as illustrated by this account from a young man: ...and then after about five months of going out, we decided to have sex. And yeah, and we, it really hurt her at, like, quite hurt her a lot. Like we'd been trying like, it sounds quite crude, but like I'd started using more fingers -instead of one, I'd use two, just so it wouldn't hurt her as much when we had sex, cos she was really worried about it. [So had you talked about that?] Yeah, we had. Like cos we'd started speaking about like, oh, do you? I feel like I do wanna lose my virginity to you and stuff. And then she told me that she was really worried that it would hurt and she doesn't want, want it to. So I was like, well, look, we can do this to make it a lot, which will probably make it easier if she does it, yeah, it's a really good idea. So we started like, I started doing it more to her and using more, more fingers. And then, and then we did it [had vaginal intercourse]. As seen in these extracts, rather than being conceived as a worthwhile practice in itself, fingering often appeared to be considered instrumental in achieving comfortable intercourse for girls through 'stretching' the vagina. This notion of the need to 'loosen' vaginas conflicts with popular discourse among young people, and others, about the desirability of vaginal tightness. As also noted elsewhere , the interplay of these two contrasting discourses constructs vaginal size as irreconcilably problematic. As well as reducing pain for women, some young men said they themselves might experience pain or even physical injury if their partner had not been properly 'prepared' for sex through fingering. For example, when a young man revealed in an all-male discussion group that he had had vaginal intercourse before ever having fingered someone, the other men appeared surprised, asking him whether she was 'wet enough', while another warned: "That might've hurt that, you know, you might've snapped yer banjo [frenulum]." Fingering was also described as necessary before any intercourse -not just first intercourse -to 'help' women 'get in the mood': Woman 1: Like you don't have sex first and then get fingered. Woman 2: What's the point? --- Int: Why not? Woman 2: Cos what's the point? How would you get in the mood? There's no touching, there's no foreplay, there's no building up. You're just going to put your willy in me and then go and then try finger me afterwards? I don't think so! Woman 3: [...] you've got to be like moist for it to be like put in you because otherwise it's going to fucking kill ya. Woman 2: And that's the reason why you get fingered first. Although the notion that fingering might be enjoyable for girls was implicit in talk about it getting girls 'wet' and 'in the mood', and although some men distinguished between clitoral stimulation and digital penetration, this was nevertheless pleasure with a purpose: to make girls want to have intercourse, and to generate lubrication for this to be comfortable. Very few participants talked about fingering as being pleasurable in and of itself, and only a few of the more sexually experienced young women said they found being fingered more pleasurable than having intercourse. Rather, as in the extract above, fingering was often constructed as 'a means to an end', with some young men questioning why they would do it if it were not going to lead to vaginal intercourse: It [fingering] is rubbish man. What do I get from that man, just that my finger starts aching, that is about it man. [Why do you do it then?] Because mostly when a guy is hard the girls get on it, do you know what I am saying, like it makes them wanna screw you. So that is the only time I really do it then, if it is going to lead to something. If it is not going to lead to nothing, I am not going to do it then. Learning to experience partnered sexual pleasure Another explanation for experiencing non-coital practices before 'losing your virginity' was that it takes time for girls to learn to experience sexual pleasure, which in our interviewees' talk often appeared to be synonymous with orgasm. Gendered expectations and assumptions about masturbation and orgasm seemed to be central here. Although ejaculation was regularly described as the 'obvious' outcome of penile stimulation for men, orgasm was described as less straightforward for women, and thus less certain to occur. In addition, while boys' first sexual experience was widely expected to be solo masturbation, rather than any partnered sexual activity, masturbation by girls was seen as less universal: "I mean all boys toss themselves off but not all girls finger themselves" ; and "boys get more practice in wanking" . This widely-perceived gender disparity in the practice of masturbation was used to explain boys' eagerness to have intercourse and girls' reluctance to be penetrated, either digitally or by a penis: The idea that sexual pleasure is unanticipated by girls until they are with a man provides the counterpoint to the conventional construction of male sexual activity as unproblematically and inherently pleasurable. While boys were expected both to envisage and experience pleasure from intercourse given any opportunity, girls were expected to need longer to learn to experience sexual pleasure in the absence of masturbation . Young women were therefore thought to require non-coital practices to help them get used to partnered sexual experiences before 'losing their virginity'. Although talk about young women enjoying non-coital and solo sex potentially opens up possibilities for de-stabilising penetrative intercourse as the ultimate goal of heterosex, accounts of women needing time -and the help of a male partner -to learn how to enjoy sex work to reproduce a gender hierarchy in which women are constructed as sexually deficient compared with men. I --- Developing intimacy in a relationship In many accounts, the incremental progression from non-coital sex to first vaginal intercourse was linked to the gradual evolution of trust and comfort within a specific relationship. These accounts were usually given by individuals who had experienced many -and sometimes all -of their sexual 'firsts' with a particular partner. While the expectation of romance and intimacy at first intercourse is widely documented among young women , and borne out in many of our interviews with women in this study, conventional gender stereotypes construct young men as eager to have sex, regardless of the nature of their relationship with the available partner. Diversity in young men's expectations of sexual intimacy, however, is well-described , as are the ways in which dominant ideas about masculinity limit how men can publicly express their hopes and anxieties about sex . In this study, some young men did talk about the significance of non-coital sex in developing emotionally intimate and trusting relationships: The idea that first intercourse needs to be preceded by a gradual 'build-up' of non-coital practices relates to what Hockey et al call the 'hierarchisation of special moments' in the production of heterosexualities. As also reported elsewhere , many young men and women in this study discussed the need for first intercourse to be 'special', and engaging in non-coital practices was part of the process of developing the required trust, comfort, and mutual intimate knowledge to create a sense of 'specialness'. For some young people, then, non-coital practices are a key part of first sex 'meaning something' in a relationship, as opposed to subsequent and/or more casual encounters which might only involve vaginal intercourse: "if I was at a party, I'd just stick it in really" . I --- Discussion These accounts help us understand the significance of non-coital sexual activities, which are often missing from theorisation of young people's sexual transitions. Our interviewees' talk about sexual development revealed a normative expectation of non-coital sexual experience before 'virginity loss'. The wide acceptance of this 'normality' is clear: not only did most young people's actual experiences conform to this norm, but where they did not, they described their experiences as diverging from the 'expected' pattern. Ideas about what non-coital sex is 'for' varied among our interviewees, especially by gender and by the types of sexual relationships they had experienced. An over-arching commonality, however, was that non-coital sexual activities preceding first vaginal intercourse were rarely described as valuable in themselves: they were usually framed in terms of preparation for first 'sex', suggesting that 'normal' sexual development is still predominantly viewed as leading to this 'inevitable' event. In this paper, we have shown how ideas about a 'normal order' to pre-coital sexual experience operate as a heteronormative discourse shaping sexual narratives and experiences long before first vaginal intercourse. Although there was some evidence of the normalisation of same-sex kissing among young women, genital contact was imagined in terms of relatively rigid heterosexual norms, with limited 'fluidity' across the hetero/homo binary. Of course it is likely that some of our interviewees will go on to have same-sex experiences and relationships. It may be, however, that the 'heterosexual assumption', and attendant expectations about different sexual practices, apply more rigidly to experiences before 'virginity loss' than after. Prior to 'having sex' young people's talk about, and experience of, non-coital sexual activities helps circulate ideas about what 'proper' sex is, which sexual practices are valued and why, which skills are required and by whom, and whose pleasure is prioritised. Gendered expectations specifically relating to 'virginity loss' are played out in prior noncoital sexual experiences; for example, the expectation that first vaginal intercourse will be physically painful for young women features in explanations of the 'need' to stretch vaginas in preparation. The restrictive effects of normative heterosexuality may affect young men as well as young women, by limiting men's opportunities for talk about non-normative experiences, and by reinforcing familiar discourses of male sexuality in terms of performance and technique . If sexual health programmes are to challenge gendered inequalities in dominant assumptions about sex successfully, non-coital sexual activities need to be viewed as a legitimate area for discussion. Such discussion rarely features in curricula, reflecting the way sexual health is often narrowly construed in terms of avoiding unplanned pregnancy, STIs, and non-consensual vaginal intercourse, with less attention paid to the quality of sexual relationships and experiences. The emphasis on vaginal penetration in sex education may also reinforce the "reproductive and hence heterosexual priority of sexual activity" by ignoring the many alternative ways of giving and receiving sexual pleasure . Young people's own understandings of the broader range of sexual practices, and the meanings they have for them, may be a valuable starting point for discussion to challenge some of these assumptions. For example, discussing 'bases and stages' could help trigger critical examination of the notion that young people should 'go as far as they have gone before', that practices should occur in a set order, that they should culminate in vaginal intercourse, or that they should occur at all. In this way we can begin to challenge assumptions about 'normal' sexual trajectories that serve young men and women unequally in achieving sexual pleasure and well being.

While the symbolic importance of 'losing your virginity' has been described in many settings, meanings of non-coital sexual experiences are often 'missing' from theorisation of sexual transitions. Drawing on data from a qualitative mixed methods study with young people aged 16-18 in England (the 'sixteen18 project'), we explore accounts about which sexual practices are considered typical, and expectations of the order in which different sexual activities first occur. Our study demonstrates how gendered talk about a 'normal order' of non-coital sexual activities 'leading to' vaginal intercourse contributes to a heteronormative discourse shaping sexual narratives and experiences long before first vaginal intercourse. Pre-coital sexual experiences were accounted for in terms of providing an opportunity for young men to develop and demonstrate sexual skill, for young women to be prepared for penetration by a penis and to learn to enjoy partnered sexual encounters, and for both sexes to develop intimacy required for vaginal intercourse. Prior to 'having sex', young people's talk about, and experience of, non-coital sexual activities helps circulate ideas about what 'proper' sex is, which sexual practices are valued and why, which skills are required and by whom, and whose pleasure is prioritised. If sexual health programmes are to challenge gendered inequalities in dominant assumptions about sex, non-coital sexual activities should be viewed as a legitimate area for discussion.

Background Health management information systems are instrumental in addressing health delivery problems and strengthening health sectors by generating credible evidence about the health status of clients [1]. The purpose of the HMIS is to ensure consistent and systematic compilation of health data, with regular analysis and interpretation to guide key decision making and programmatic interventions [2,3]. It is through an effective and functional HMIS that the burden of disease and utilization of services can be appropriately determined [4]. Several countries in sub-Saharan Africa have established a national HMIS [5], with varying experiences with their implementation [6,7]. Uganda's HMIS is more established, formed in 1985 to collect and analyze national data on morbidity from communicable and non-communicable diseases, family planning , reproductive health , and immunization [2]. RH and FP data collection and reporting was initially paper-based, but is now both paperand web-based [5,8,9]. The routine health data reporting system has evolved to the current platform, known as the district health information software, version 2 , which began in 2011 in a few districts and was rolled out to all districts in Uganda in 2012 [8]. In Uganda, the district is considered a self-contained geography entity that presents a good opportunity for integration of multiple health programs. All public and private health facilities in Uganda are mandated to report health data to the district through the HMIS. Family planning services in public health facilities are usually provided by the government through the national healthcare system. FP services in the private non -government sector are provided by private for-profit and private not-for-profit facilities, including faith-based organizations and non-governmental organizations . The Ministry of Health manages health system in Uganda through its two national referral hospitals , regional referral hospitals, district hospitals, and health centers [3,8]. --- Problem statement Uganda has registered improvements in some FP indicators. For instance, the modern contraceptive prevalence rate among married women increased from 8 % in 1995 to 35% in 2016. Still, contraceptive use in Uganda lags behind other countries in East Africa [10]. Sustaining the momentum of this progress requires, among other interventions, regular generation of complete and accurate FP information to facilitate appropriate programming and policy-making. The public and private sectors independently report RH information to the national level [6,11]. In low-income countries, the private sector is often perceived to be more efficient, accountable, and sustainable than the public sector. However, studies have shown that RH information, including FP, is not yet integrated in some countries [8,12]. Available evidence in Uganda mainly focuses on the public sector [8]. In Uganda, FP information was captured separately from the private and public sectors until the recent adoption of a newly-integrated HMIS focusing on immunization, HIV/ AIDS, and FP services [5,8,13,14]. However, not all public and private health facilities are included in this new system. This has created a fragmented picture of the FP situation in Ugandawho is using FP services, how effectively are these services being provided, and where are the breaks in FP uptakeleading to a gap in the evidence base for informed decision-making. There is paucity of studies, which have explored the facilitators, best practices and barriers to integrating FP data from the public and private health sectors into national HMIS, in sub-Saharan Africa in general and Uganda, in particular. Both facilitators and barriers can both be grouped by technical, organizational, and behavioral factors [5,6,8,[15][16][17]. --- Study objectives Therefore, the objectives of this descriptive study were to investigate the facilitators, best practices and barriers associated with the integration of FP data into the HMIS in Uganda and develop recommendations to improve the integration of FP data. --- Data and methods --- Study design Based on recommendations for evaluating an HMIS, we used the Performance of Routine Information System Management framework to guide the study [5,6]. This was a cross-sectional, qualitative study based on key informant interviews and a one-day participatory multi-stakeholder dialogue workshop. The study was conducted between 2016 and 2017. --- Sampling procedure The study was conducted in Kampala , Jinja, and Hoima Districts. Jinja and Kampala are urban while Hoima is mostly rural. The study participants were designers of HMIS templates, users of the electronic or paper-based HMIS forms , and FP data users. The sample size was determined based on maximum variation focusing on potential sources of data. Two districts where the DHIS 2 was implemented were purposively selected [8]. A similar approach was used in Zambia [18]. From these districts, we selected three public and three private health facilities. Kampala District was included since it hosts the Ministry of Health and therefore the national level key informants. The study recruited 27 participants, including 16 key informants and 11 MSD workshop participants. A similar approach for recruiting MSD participants has been used elsewhere [12]. Five members of the research team participated in the MSD workshop. --- Inclusion and exclusion criteria The inclusion of study participants was based on their knowledge and experience with Uganda's HMIS. Participants were selected from the MOH department in charge of HMIS and MROs from the MOH and public/private/ NGO health facilities, FP organizations, district biostatisticians, and records officers working on the HMIS. For the MSD workshop, participant selection was also based on knowledge and experience with Uganda's HMIS. Participants included key informants in the study and other policy or program stakeholders closely linked with HMIS. --- Data collection Primary data collection included KIIs and the one-day MSD workshop. Participants included district officials, MOH officials, staff from public and private health facilities responsible for collection, oversight of HMIS and utilization of outcomes, and employees of donor-funded implementing partners and stakeholders addressing FP and those with a stake in HMIS. Consent to participate in the study was obtained verbally. --- Key informant interviews Sixteen key informants were interviewed using and KII guide . The three MOH officers interviewed were from the HMIS, RH, and records departments. The interviews facilitated access and analysis of the MOH's updated FP/RH data collection form. Interviews were aimed at assessing whether data from the two sectors are integrated for planning purposes; determining the feasibility of integrating public and private FP data; examining the consistency of data capturing in public and private sectors; and identifying facilitators and barriers of the process, lessons learned, and recommendations with respect to integration. Three program personnel from a multi-lateral organization and NGOs working in FP were selected. The organizations were United Nations Population Fund , Reproductive Health Uganda, and Programme for Accessible Health Communication and Education . The researchers collected expert views on the feasibility of integrating public and private FP data. Four biostatisticians, six MROs, and two HMIS focal persons were interviewed to establish the existence and utilization of HMIS data collection forms in the private and public facilities in the districts, the facilitators and barriers involved, and whether data from the two sectors are integrated for planning purposes . Six health facility-based MROs at public and private facilities that provide FP services were interviewed to assess the contents of data collection forms from the various providers for comprehensiveness and consistency, and to determine whether FP data are actually collected. This involved six health facilities: three public and three private facilities, in the two districts. --- Multi-stakeholder workshop The one-day MSD workshop held in February 2017, was conducted to obtain an overall perspective on the content, approaches, barriers, facilitators, best practices, and recommendations for public-private FP/RH HMIS data integration . The workshop involved 11 participants, who were key public and private FP stakeholders and some of the key informants. We used adult facilitation approaches such as visualization in participatory planning tools for instance brainstorming and use of cards for idea generation, clustering, prioritizing, and discussion and small group discussions [19]. The rationale for using both KIIs and the MSD workshop was to enhance triangulation of methods and validation of findings from the former. --- Data analysis The KIIs and MSD were audio recorded, transcribed verbatim by professional transcribers, and the transcriptions were checked for accuracy by the research team. Deductive and inductive thematic data analyses were used to analyze the transcripts. The PRISM framework, an innovative approach to designing, strengthening and evaluating routine health information systems, was used to guide the analysis. The framework supported thematic analysis by providing a systematic model for managing the data. It also guided the data coding process and presentation of results by providing a priori themes or framework for developing themes of analyzing the data [5,6,20]. --- Results Based on the PRISM framework analysis [5,6], the study findings are organized based on the technical, organizational, and behavioral facilitators and barriers to integrating FP data from the private and public sectors in the national HMIS in Uganda. --- Facilitators of FP data integration in the national HMIS Technical facilitators The HMIS in Uganda is a standardized and integrated national reporting system. Standardized electronic and paper-based forms are used. Although the MOH is encouraging electronic-based data collection and reporting at all health facilities, the norm in private facilities and some lower-level and rural facilities is still to use paper-based forms due to shortages of computers, power, and internet connectivity. All health facilities are required to use the MOH's standardized forms to avoid duplication of data and reduce overload of reporting to the HMIS. Records from community health workers are captured at the nearest health facility. The system requires adherence to correct procedures for compiling data and is designed for continuous cross-checking of data to eliminate errors. An example of a standardized form is HMIS Form 105 which reports monthly attendance figures for maternal and child health and FP visits, diagnoses for the outpatient department, laboratory tests, HIV and AIDS service data, stock outs of essential drugs and supplies, and financial data [21]. At a lower-level health facility, a records officer observed the following: Everything is incorporated within that user form. It is integrated and so FP data is catered for. Similarly, a national-level stakeholder observed: All facilities use standardized forms for reporting; the individualized and special reporting by health facilities was abolished. Thus, there is less confusion and less workload given the similar tool used in data collection at all levels. Most HMIS personnel at the district level had access to computers. Implementing partners, such as The AIDS Support Organization provided computers to their partner health centers in Jinja. The introduction of DHIS 2 by the MOH, with provisions for web-based reporting, strengthened district -based and national-level reporting. District-level HMIS personnel found the DHIS 2 software appropriate and user-friendly. Web-based reporting makes sharing health data easier among stakeholders who have user rights and can access the system. It allows IPs and donors to monitor and scrutinize the quality of data being collected. A national-level key informant made the following observation concerning HMIS: It is an online system that captures all the paper forms as electronic and data is sent electronically. It is a server and at the same time entry point. Biostatisticians run through the data to rectify errors. Some errors are rectified automatically but others are sent back to the facility. Web-based reporting is an innovation which does not require district HMIS officers to submit data to the ministry in hard copies, hence reducing on the transportation costs as well as minimize paper use. A key informant from Hoima District noted the following: It is one of the best data collection systems we have in the country. I have had experience overseeing Buhanguzi Health Sub-District, which has 26 facilities. The system is easily adopted by the officers, and reporting becomes easy. In particular, since 2013, there have been tremendous positive changes [in reporting]. --- Organizational facilitators The Government of Uganda prioritizes FP in line with its commitment to international and regional conventions . Owing to this commitment, there is substantial emphasis on improving FP service provision and consequently collecting FP data. In addition, FP is among the country's priority areas since the contraceptive prevalence rate is monitored at the national level. In order to ensure compliance with the HMIS, the MOH has linked submission of HMIS reports with license renewal for private health facilities. All health facilities are required to regularly submit HMIS reports to the district HMIS office. For private facilities that are not reporting consistently or fail to report, a condition stipulates that prior to the renewal of their health facility license, they must submit all missing reports to the HMIS district office. For public health facilities, when submission of HMIS reports from any one district is delayed, the records assistant receives follow-up phone calls from the district HMIS focal person asking him or her to explain the delay. At the end of the year, penalties are imposed upon districts with very poor performance. Availability of HMIS forms in registered and licensed health facilities facilitates the HMIS in Uganda. These forms must be submitted to the districts and, thereafter, to the MOH. FP data from community outreach programmes by private or NGO providers are captured using government health facility registers. A national-level informant noted the following concerning public facilities: The forms are available especially in the public health facilities. You find forms in all health facilities. Even recently, in the remotest health facility in the Karamoja Region, they had the HMIS forms. In addition, continuous review of the HMIS forms has been a favorable condition. Every 5 years, the MOH invites all HMIS stakeholders and health unit staff for a meeting to provide input on improving the HMIS forms. Training designated staff in HMIS data management is a critical facilitating factor. While Hoima District reported universal training coverage, Jinja's training coverage was reported to range from 50 to 90%. Many officers reported receiving training in HMIS data management several times . Trainings address computer literacy, navigating DHIS 2, data analysis, and updates on the contents of the form. In Hoima District, all health staff attending to outpatients had been trained on HMIS data collection, including FP. A biostatistician pointed out: There is improvement in quality. I am not saying that [it] is very good data, but there is improvement in quality because of this regular training and introduction of this web-based reporting. I think these contribute to quality because before they would collect all the data and bring to the ministry to enter and you know what it means-and now sometimes the data entry is done at the facility. Supportive supervision is among the key components of the HMIS. Health facilities receive quarterly visits, mainly from district officials, and supportive visits from MOH officials. IPs, such as the World Health Organization, the United States Centers for Disease Control and Prevention, and World Vision support and participate in supervision and trainings and are usually available for consultation. Facility-level records officers receive supervisory visits from district HMIS focal persons and organizations and donors such as the United States Agency for International Development , World Health Organization, World Vision, PACE, TASO, and Infectious Diseases Institute . The MOH, through the Regional Performance Monitoring Team, conducts quarterly visits to the districts and occasionally to health facilities. Visits are followed by review meetings on how to improve service delivery. The team supports networks and linkages between IPs and health facilities. In general, the HMIS was reported as having adequate human resources, facilities, software, and forms. In addition to government and USAID support, districts mobilize resources through collaboration with IPs. Such IPs support capacity building, training, service delivery, and commodity provision. Examples of IPs associated with FP programs in Uganda are Reproductive Health Uganda, Marie Stopes Uganda, World Vision , and IDI. Monitoring and Evaluation Technology Support, a project based at the Makerere University School of Public Health that is interested in data, supports printing DHIS 2 forms for all health facilities and monitoring all data-related issues. TASO receives data from the 17 higher-level health facilities it supports. TASO staff receive free data bundles from Mobile Telecommunications Network that facilitate access to the MOH website. --- Behavioral factors A high level of appreciation and motivation of data users and managers is a key facilitator for enhancing HMIS performance in Uganda. IPs provided financial incentives to biostatisticians and HMIS focal persons in both Hoima and Jinja Districts. Users and managers rated the HMIS as one of the best data collection and health management systems covering different health aspects. All respondents except one were motivated to work with the system because of their interest in data analysis , data management experience, and desire for high-quality data for planning purposes. In support of the system, a national-level officer from an NGO observed: No work documented is no work done. People should be encouraged to document what they have exactly done. Most respondents noted that health personnel were generally competent and had been cooperative in executing HMIS tasks. Relevant personnel exhibited flexibility and willingness to adapt new methods and the addenda included in the HMIS forms. Since training programs entail assessments, personnel work hard to protect their names and positions since they value their jobs. In addition, team work is promoted among the HMIS personnel, which contributes substantially to the quality of outcomes. A national-level and district-level respondent, respectively, said: Team work is key. Where staff work together in generation, entry and discussion of the reports has yielded quality data. In some districts, district health teams meet every end of the month to check data quality. We do our work then at the end of the month, we sit on a round table. We compile, analyze, and then submit. If there are any errors, again we talk about them and you know. It is not a one man's business. Collaboration or networking with other districts or actors is beneficial to the process of data management. Partnerships have made work easier and contributed to improvements in meeting reporting timelines. With respect to consistent use of HMIS forms, national informants noted that public health facilities are more consistent in health information reporting because staff's access to the forms is guaranteed and ensured. Unlike private facilities, public facilities receive regular supervision. An MOH informant observed that low coverage of HMIS forms at private facilities is attributed to fewer trained staff at those facilities: In the private sector, reporting is less than 25%. Apart from recording the name and date of review or reattendance, nothing much is done in the private facilities. Staff need to be brought on board, to be trained and then mentored on how useful it is to capture data. Health facilities receive reminders from the district office when reports are due. All health facility records staff are expected to prepare HMIS reports for submission as stipulated in the HMIS health unit procedure manual [3]. In this manual, each health unit is expected to keep a register of all patients that is updated daily. From the register, tally sheets are used to populate the HMIS reporting forms. A records officer elaborated on the process as follows: Data are captured on a daily basis at the health facilities using the 031 form. Weekly, we report on surveillance, and that is Form 033B. We also have a monthly report and this is usually on the general condition in the facility like drugs, store medical, theatre, etc., and this is HMIS 105 for outpatient and 108 for the inpatient. Quarterly, we compare three months' information and it's done manually. Then we have the annual report that is HMIS 107 where we generate all months and come up with one report. Finally, we have the financial year report. Reporting is done on a weekly basis using mobile tracing -a health system strengthening tool using text messaging. Data reported via text through mTrac are immediately made available within DHIS 2 for further analysis. A parallel system entails submitting hard copies of the tally sheets to the facility HMIS focal person. A provider prepares a monthly report and submits it to the district HMIS officer by the seventh of the following month for compilation and entry in DHIS 2. Monthly reports contain detailed health information from all health facilities. The district HMIS office submits all reports electronically to the MOH Resource Centre by the twenty-eighth of the following month. The MOH Resource Center disaggregates data by district, health center, and type of health facility . Standardized and convenient data transmission procedures are used. Personnel involved in data transmission are trained in reporting procedures. Furthermore, the online reporting form makes it easy to detect mistakes. The process has been simplified with the mTrac system enabling mobile phone users to send data for weekly reports. A records assistant from Hoima reported: We used report on a weekly basis but right now we no longer do so because we are provided with the mTrac system. So, we can use our phones to send data. Now we send weekly reports using [the] mTrac system using Internet on our phones. Health facility in-charges are advised to allow records personnel to submit data directly to the district since the records personnel must receive feedback from the district on their submissions. Data in the national database can be easily retrieved and used for decision making. Feedback at the various levels is both bottom-up and top-down. Districts provide supportive supervision to health facilities and advise staff on areas for improvement. District teams help health facilities address challenges and facilitate a process in which the worst-performing health facilities can learn from the best-performing ones. The DHIS and IPs communicate concerns about data accuracy and reporting time. Reports are graded and performance is displayed, which is a motivator for better performance. IPs also regularly share information, provide feedback, and suggest recommendations for improvement. This was particularly the case in Jinja District. The MOH provides feedback to districts on the quality of reports, data cleaning issues, reporting rates, timeliness, system issues, and performance. Coaching visits are conducted and, in such sessions, district personnel coach and obtain feedback from health facility personnel, and vice versa. Quarterly performance reviews are conducted at the national level to provide feedback to relevant personnel. These meetings ensure that data collection and reporting is in line with HMIS data collection and reporting procedures. During performance review meetings, district HMIS focal persons and health management team members review the performance of each health facility. They then request staff from facilities that are performing well in terms of timely reporting to share with other facilities to facilitate adoption of good practices. Similarly, staff from facilities that are not performing well are requested to share their experiences, why their performance is not up to standard, and how they can be assisted. One stakeholder from Jinja District explained: We normally conduct performance review meetings quarterly. We look at how facilities have performed in different areas. Sometimes we spot out the best-performing facilities and the worst-performing facilities and we look at how the best ones have been managed and then we look at the worst-performing ones and what has caused them not to perform so that they tell us because of: say, "It is hard to reach," "We are at the island so while trying to reach the place the boat got a problem and we took two weeks." We share all that in review meetings. Collaboration between the MOH and IPs has been key. Although the MOH oversees HMIS implementation within the districts, it collaborates closely with IPs that support HMIS work through capacity building, training, service delivery, supervision, and commodity provision. Such IPs include USAID, the Centers for Disease Control and Prevention, World Health Organization, Marie Stopes Uganda, PACE, and IDI. Companies, such as the Mobile Telecommunications Network, support the HMIS by providing free data bundles to HMIS staff. This facilitates communication and results in faster access to MOH websites and improved use of DHIS 2 software. According to a national-level information officer and a records officer, respectively: These partnerships have "made life easy." It is easy to address challenges, there is improvement in timelines in reporting. IPs also offer financial support. --- Best practices for an integrated HMIS Based on the facilitators, we identified the following best practices for integrating public and private data into one HMIS. These best practices pertain to not only FP data, but all health data: Integrating Uganda's HMIS reporting system. It contains all relevant health information, including FP, in one place. Consequently, there is one set of forms and no duplication of reporting in the district health information system and national HMIS. Conducting routine performance reviews. This creates opportunities where the worst performing facilities can learn from the best performing ones. Enforcing data reporting compliance. We found that conditioning renewal of licenses for private facilities on submission of required records and reports is effective for ensuring data reporting compliance. Engaging stakeholders in designing and reviewing HMIS forms. HMIS use improves when IPs and relevant partners are actively involved in developing and reviewing HMIS forms. Collaborating between the government and IPs. Systems, including the health information system, are strengthened when collaboration and networking occur between the MOH and the IPs, including the districts and civil society organizations. Embracing new technology. Demonstrating flexibility to take advantage of technology, such as using mobile phones for data transfer, makes the adoption of new technology smoother. Prioritizing staff capacity building. This includes continuous training, and in some cases, coaching HMIS staff, supportive supervision, and provision of feedback on data reporting at various levels. Supporting teamwork among HMIS personnel. When team members share the workload and their data expertise, data reporting and data quality improve. --- Barriers to FP data integration in the national HMIS Technical barriers The complexity of the HMIS reporting form and procedures is challenging. Respondents noted that the reporting form is very long , lacks adequate space for capturing data and does not have a place to indicate the sex of the FP user. Some codes used for FP data on the form are not available in Ugandan health facilities. The form does not provide explanations on meaning of the codes. Furthermore, some of the contents are not applicable to lower-level facilities. A district level informant intimated: The reporting form is not user-friendly. It has many pages with lots of information requirements. This makes it hectic. So, often times staff submit incomplete and inaccurate forms. The paper-based reporting forms and the online platforms have not been completely harmonized. Some of the data captured on the paper-based HMIS forms are not incorporated in the online DHIS 2. In addition, records personnel are sometimes asked to collect and capture information that is not on the paper-based form. This leads to submission of incomplete and inaccurate forms. The volume of the tool and manual is huge, which is a disincentive to staff. Although regular revision of forms is good practice, it takes time for records personnel to become familiar with the revised forms. The implication is that if a facility uses an older version of the tool, some information is missed or not filled in. Although two-step data entry could have value with respect to quality control, double entry of HMIS data makes the procedures strenuous. Records assistants are required to fill out hard copies of the forms that are later submitted to the district biostatistician for entry in DHIS 2. It would take less time if data were entered directly in the system and thereafter verified by the biostatistician or HMIS focal person. Some of the records officers reported that they were trained in information systems and can handle the online system. Besides the lengthy form, some health facility personnel found the DHIS 2 software slow in generating reports. The form is designed in such a way that it does not upload when there are missing data. Despite the availability of computers at the district level, some lower-level facilities at the sub-district level still lack computers. This presents a challenge for data entry and verification. The lack of computers increases the workload of the district biostatistician and HMIS focal person. Most facilities use traditional client registers to extract data and populate the HMIS reporting forms, which are later submitted to the district HMIS focal person. At the district level, most of the computers have old versions of computer software, lack antivirus protection, and are poorly maintained. There are problems with Internet connectivity, which delays the transmission of data to the MOH HMIS dashboard. Similarly, inconsistent power supply at the district level delays data transmission to the MOH servers. Not all facility-or district-level staff have access to the MOH dashboard. Sometimes personnel that can access to the system and dashboard are busy and cannot give information when it is required. --- Organizational barriers Staffing for the HMIS is inadequate. A senior biostatistician from the MOH reported that only five of the 15 national-level staff are available to supervise the HMIS. This is a limited number given the workload and the effort needed for effective implementation of the system. At the district level, the biostatistician is expected to capture data from all health facilities in the HMIS and perform data assessment, analysis, and validation. This heavy workload affects the timeliness, completeness, and quality of the district reports. In some health facilities, only one nurse provides FP services. Shortages in human resources result in late and under-reporting of FP data. One district-level informant said: I am the only person in this office who captures data from all the health facilities into the system, does data assessment, analyzes, validates, and everything else. Public facilities usually have fewer staff. Therefore, because of the heavy workload, staff on duty may not record FP services. Private facilities, on the other hand, may be required to report to other agencies in addition to the mandatory reporting at the district for the MOH, leading to reporting fatigue. Constant training on the HMIS is required due to high staff turnover or attrition, especially in private facilities. A key informant from Hoima District reported that staff in private facilities frequently leave for better opportunities, resulting in recruitment of unqualified and inexperienced personnel to handle HMIS data. This creates the need to recruit and retrain new records personnel for such facilities, which is both costly and time-consuming. When forms are revised, not everyone is trained on the changes, and this creates a barrier for data quality. Some records assistants had neither received adequate training nor refresher training. One district-level informant added: I have never heard of nurses and midwives going for refresher training on family planning data in the HMIS. Irregular training in the context of staff attrition in private facilities and revision of HMIS forms, negatively affects data quality in terms of accuracy and completeness at the district level, since responsible personnel have to learn on the job. Several health facilities were reported to have stock outs of HMIS forms and stationery, which affects reporting. Sometimes stationery is not provided in time and districts have no budget for printing and photocopying materials for the facilities. Jinja District reportedly went without in-patient registers for a couple of years, and many facilities do not have FP registers. This leads to compilation of incomplete FP data since some records are made when services are provided to clients. Registration and coding of facilities in the national HMIS by the MOH takes a long time. The district usually monitors and assesses a health facility before incorporating it in the HMIS despite commitments from IPs such as PACE. This contributes to incompleteness of data because the system is not covering all health facilities in a districts. There is lack of support for FP data from management in some religious health facilities. For example, in some Catholic health facilities the FP section is left blank and is therefore recorded as incomplete. --- Behavioral barriers There is a general lack of interest in and demand for FP data on the part of IPs. Limited attention is given to FP data at the health facility level, thus affecting data quality. Heavy workloads, especially in private health facilities, which may not have designated records staff, have the potential for FP compromising data quality. Health workers who already burdened with heavy workloads, are also responsible for record keeping. In such contexts, record keeping and documentation of FP data is often deemed a secondary priority. Hence, opportunities for checking data quality are limited. There are challenges in collecting data on FP services provided by village health teams during community outreaches. In some cases, the services are not always recorded by health facilities. In addition, some records assistants have difficulty interpreting the FP codes that are found in the HMIS forms, leading to submission of incorrect data or information. One national-level informant reiterated: A case in point are entries related to condoms. So, one is required to fill in a number. However, the question is whether they are referring to packets or number of individual condoms taken by a person. So, the response expected is not clear and these data remain vague. Some records assistants focus on other indicators compared to FP, so they often have no statistics in the respective entries. With respect to completeness of information, informants noted that overall, reporting is around 87% for public and private facilities together. The delays are sometimes caused by lack of resources for transporting the paper-based forms to the district office, or misplacement of the forms by the relevant district staff. Too many reports are required by the MOH, leading to heavy workloads for the HMIS focal person and district biostatisticians. IPs also have too many data demands but are given priority at the district level since they support district programs. --- Discussion This study investigated the facilitators, best practices, and barriers associated with the integration of FP data into the HMIS in Uganda. Qualitative data from key informants and a MSD workshop were conducted. --- Facilitators of FP integration in Uganda's HMIS In Uganda, the national and district HMIS are integrated with FP and RH data entered in the same system . The integrated web-based reporting system addresses challenges presented by parallel systems, one of which is fragmentation of data [22]. In addition, the integration of data from both private and public hospitals has led to improved health outcomes through the monitoring of health service coverage. However, to achieve full integration, provision of adequate information technology infrastructure, ranging from first-level health facilities to national referral hospitals, should be rolled out [23]. The HMIS software was reported to be a user-friendly, and efficient web-based reporting platform. Several studies reported that user-friendly software improves data collection, transmission, and quality [6,[24][25][26]. On the other hand, HMIS staff at lower levels found online reporting problematic. During the peak time for submitting reports, the DHIS 2 platform tends to slow down as several users congest the web traffic. In addition, with errors and missing data, reports are inaccurate, unreliable and difficult to submit. This experience becomes challenging for the users [6,8,[24][25][26]. Engaging different stakeholders in HMIS planning and design was essential success in Uganda. A study in Ghana and South Africa highlighted that consultations with different stakeholders and collaborative networks are essential for improved performance and sustainability of HMIS [22] and the success of national HMIS [24]. Our findings are consistent with the literature demonstrating that on-the-job training, with respect to Uganda's HMIS, improves performance through timely and increased reporting of key health indicators [8]. A similar study in Uganda examining the effectiveness of the PRISM tool found it to be user-friendly, reliable, and valid. The study further demonstrated that the PRISM methodology can be used effectively by routine health management information system [5]. Barriers to FP integration in Uganda's HMIS HMIS programs in SSA countries, including Uganda, face diverse challenges such as poor infrastructure, inadequate human resources, logistical issues, inadequate office equipment including computers and software, and uncoordinated collection and use of health information [8,25,[27][28][29][30]. This often leads to incomplete and inaccurate reports, which compromise the ability to use the data to inform decisions and ultimately improve health service delivery [2,8,9,31]. Our study results concurred with these findings. This study reported long and complex HMIS forms, double entry of HMIS data and web-reporting challenges as the most critical technical challenges to FP integration in the HMIS. Not all FP data codes reflected the commodities available on the market. There was no place to indicate the sex of the FP client, which is critical for programs working to address male engagement in FP. The tedious time consuming process that entails double entry of HMIS data on the online DHIS 2 platform and paper-based versions, which demotivates health personnel is not unique to Uganda [29,31,32]. Our findings indicate that FP data from the HMIS are not utilized at health facilities. Priority is given to data collection and reporting to the national level. Several studies have reported a poor culture of information sharing and use related to HMIS data [18], especially at facility and district levels. This is attributed to heavy workloads, as service providers double as record officers and analysis usually takes place at a higher level, where data collectors lack access. The importance of the various categories of data collected under FP needs to be explained to data collectors. When data quality is poor, the generated data is deemed unreliable and is therefore rarely used for planning and programmatic purposes. Hence, symbolic rather than functional use would apply [18]. A study in Tanzania reported a similar finding where HMIS data were not used at the health facility level [30]. Successful HMIS tend to be action-led where collected data are used to inform local decision making before being reported to the national level. Our findings show that use of data for planning by district and facility staff is limited [22]. Although reviewing FP data collection forms is beneficial, the review should be tailored to the national context. Reporting requirements for contraceptive commodities and services that are not applicable in the national context or at various facility levels should be removed. It is important to ensure that systems collect essential rather than "nice-to-know" information [22]. Our study found human resource constraints regarding HMIS implementation. The challenges are more pronounced in the private for-profit health facilities, where in some cases records officers are not hired or attrition is high [18]. Similar challenges were reported in Tanzania [30]. Although national stakeholders are generally satisfied with the tools and reporting process, facility-and district-level staff report heavy staff workloads [32]. HMIS is a laborious and prolonged reporting system [33]. --- Recommendations Based on the barriers discussed, we developed several recommendations: The MOH should regularly review HMIS forms so they correspond with the available FP commodities in Uganda and are aligned to the FP services provided at the health-facility level. In addition, data collection forms should provide a key for the FP codes used to collect HMIS data. During trainings, emphasis should be placed on ensuring service providers adequately understand the codes. The MOH should provide feedback to HMIS program designers at national and district levels to address missing FP data. This should be done to reconcile data collected on paper-based forms with data in the online forms. A review in Malawi concluded that one of the three core recommendations for improving HMIS is strengthening data collection tools [34]. The MOH HMIS department should ensure availability of forms at the district level with follow up at lower levels to ensure that private facilities access the forms. This includes creating a budget to produce copies of forms for all public and licensed private facilities. Furthermore, districts should ensure that all health facilities use updated HMIS forms. In addition to hard copies, soft copies of the HMIS forms in easily downloadable formats should be made available on the MOH website for public-and private-sector program personnel to download or use. The MOH should extend the computer-based system to the lowest-level health facilities [23]. A computerized HMIS would facilitate FP data analysis and would address issues of double entry . Development partners should support the HMIS program by providing computers, internet connectivity and power backup to all eligible health facilities. Servicing of computers and replacements, where needed, is essential. Private health facilities should recruit required MRO staff to address the heavy workloads resulting from inadequate staffing. Approaches for motivating and incentivizing staff should be devised for better staff performance. The Government of Uganda should target Jinja District for initial and refresher trainings for staff. The private sector should equally benefit from the training. In addition, continuous on-the-job training of health staff in all cadres is essential to enhance performance of the HMIS, particularly when HMIS forms are revised. Pre-service trainings should adequately integrate and address HMIS concepts [30], and the HMIS should be included in training curricula [32]. The Government of Uganda should consider reviewing the training curriculum for health professionals to integrate computer skills, as was suggested and implemented in Nigeria [35]. Persons involved in data collection at the community level , as well as nonclinical facility-based staff, should be thoroughly trained on the data collection forms, especially for public health facilities [30]. Trainings should aim at improving technical skills, such as information technology skills [14,36,37]. These efforts will build the health human resources capacity and, therefore, data quality [34]. HMIS centers of excellence, partnerships, and collaborations can be formed to deliver such trainings in Uganda [38]. There is need to train staff at district level to analyze and use data for fast response to local health issues. Motivation, mentorship, and supervision strategies should be devised to ensure that the records personnel, including staff at private facilities, appreciate the need for accurate, adequate, conclusive, and timely FP data in the district and national HMIS. Including the private health sector in these strategies has been recommended in Uganda [8,14]. More efforts should be directed towards promoting a culture of information use and sharing across health facilities, especially at the lower levels. A Ugandan study alluded to this need [5]. Regular data-use workshops have been identified as one of the best ways to promote HMIS data use [11]. HMIS personnel should be sensitized about the importance of the generated FP data. --- Strengths and limitations of the study One of the strengths of this research is the methodological triangulation, starting with KIIs and validating the findings with an MSD workshop. This approach enabled us to verify and validate what key informants had reported as individuals, while making discussions as a team of respondents. We explored different experiences and perceptions by interviewing a wide cross-section of HMIS stakeholders, including those from the MOH, UNFPA, NGOs, and public and private health facilities within purposively selected DHIS 2 implementing districts. However, the key limitation of the study is that both the KIIs and MSD workshop were based on a small and purposively selected sample. As a result, the informants' views may not be representative of all HMIS officers and users in Uganda. There is limited literature on HMIS and FP, in Uganda specifically and in SSA in general. --- Conclusions Family planning data collection and reporting is integrated in Uganda's district and national HMIS. The program exhibits potential for improving RH service delivery in the health system. However, limited priority and attention is given to FP data collection at both the health facility and national levels. Even when the data have been collected, they are not utilized by the relevant health facilities. Similarly, HMIS web reporting seems to be a user-friendly system, as reported by national-level stakeholders. Stakeholders at the national level, and even district officers, were impressed by Uganda's HMIS. However, the users of the system at lower levels, such as MROs, reported experiencing a diversity of technical challenges. Reviewing and strengthening HMIS data collection forms to reflect contextual realities is essential. The Government of Uganda should ensure availability of HMIS forms at health facilities and that all staff involved in HMIS data reporting are trained to enable them to ably support the units and track FP data inclusion. In addition, it is important to encourage and motivate HMIS staff and health facility in-charges to take interest in the FP data. The study provides important preliminary insights into factors shaping Uganda's HMIS FP data integration process. --- --- Additional files --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Health management information systems (HMIS) are instrumental in addressing health delivery problems and strengthening health sectors by generating credible evidence about the health status of clients. There is paucity of studies which have explored possibilities for integrating family planning data from the public and private health sectors in Uganda's national HMIS. This study sought to investigate the facilitators, best practices and barriers of integrating family planning data into the district and national HMIS in Uganda. Methods: We conducted a qualitative study in Kampala, Jinja, and Hoima Districts of Uganda, based on 16 key informant interviews and a multi-stakeholder dialogue workshop with 11 participants. Deductive and inductive thematic methods were used to analyze the data. Results: The technical facilitators of integrating family planning data from public and private facilities in the national and district HMIS were user-friendly software; web-based and integrated reporting; and availability of resources, including computers. Organizational facilitators included prioritizing family planning data; training staff; supportive supervision; and quarterly performance review meetings. Key behavioral facilitators were motivation and competence of staff. Collaborative networks with implementing partners were also found to be essential for improving performance and sustainability. Significant technical barriers included limited supply of computers in lower level health facilities, complex forms, double and therefore tedious entry of data, and web-reporting challenges. Organizational barriers included limited human resources; high levels of staff attrition in private facilities; inadequate training in data collection and use; poor culture of information use; and frequent stock outs of paper-based forms. Behavioral barriers were low use of family planning data for planning purposes by district and health facility staff. Conclusion: Family planning data collection and reporting are integrated in Uganda's district and national HMIS. Best practices included integrated reporting and performance review, among others. Limited priority and attention is given to family planning data collection at the facility and national levels. Data are not used by the health facilities that collect them. We recommend reviewing and tailoring data collection forms and ensuring their availability at health facilities. All staff involved in data reporting should be trained and regularly supervised.

INTRODUCTION Social networks, and the various forms of social capital they confer on their members, have been extremely popular areas of social research in the recent past . Within this large body of research much focus has been on characterizing the structure and function of networks and examining the consequences of social networks for individual outcomes . Fewer studies have focused on how social networks evolve in response to outside factors and, furthermore, what the implications of this evolution may be for household-and community-level risk management, vulnerability and development. In the developing world, where social welfare projects are absent or limited, social networks are critical components of household security, disaster relief, and social wellbeing, especially in rural areas . Of special importance are networks wherein the exchange of material goods 1 helps to alleviate food insecurity , smooth consumption and raise funds to address other concerns including health issues . Ultimately, networks of this kind serve to manage risk and reduce vulnerability within communities and may serve many other purposes including supporting the capacity low/high severity), utilization of natural resources and resulting environmental degradation, capacity for collective action, and exposure to opportunities and constraints associated with inclusive vs. exclusive social networks. Regarding social networks more broadly, we also view shifting risk management strategies as a potential signal for a more wholesale social network transition. These considerations are reviewed in greater detail in the discussion section. --- Social networks of exchange Broadly defined, social networks are structures of individuals or institutions, which are held together by some form of interdependency. They have become a major area of interest in several fields across the social sciences . In 2009, Borgatti noted that the number of papers in the Web of Science on "social networks" nearly tripled in the preceding decade . This is not surprising given the diversity of ways in which social networks facilitate the production and exchange of information and material goods at various scales. The history of network analysis in the social sciences is quite well reviewed elsewhere . Reviews have showed that researchers have been especially concerned with the structure of social networks including issues of centrality, connectedness, openness, and density . Borgatti points out that while there have been many studies of the determinants, or antecedents, of network connections, the "primary focus of network research in the social sciences has been on the consequences of social networks" . One avenue of scholarship on the consequences of social networks has focused on natural resource management and governance . Some have argued that social institutions and networks are important components of social capital and adaptive capacity and are central to strategies to protect biodiversity and adapt to changes in natural capital brought about by climate change . Others have claimed that some network structures are more supportive of equitable and effective management than others . Many recent empirical studies on social/ecological systems have focused on the role of social networks in shaping governance outcomes in the developing world . In doing so, they have tended to focus on information exchange and collective action to manage resources and/or resource crises. Fewer studies have focused on the exchange of material goods between individual actors or households -a particularly salient issue where the subsistence strategies for rural households in developing countries include the harvesting, consumption, and exchange of natural resources and consequently hold profound implications for resource management and biodiversity conservation. As with social networks, the history of scholarship on social exchange is extensive and very capably discussed elsewhere . Research in development economics on agrarian societies has focused on exchanges and/or transfers to manage risk. Much of this research has focused on the effect of structural characteristics of social networks on risk-sharing outcomes , and the efficacy of transfers on risk pooling and income . Studies focused on the determinants of social networks of exchange and insurance have identified geographic and social proximity , shocks , income and altruism as important factors. It is unfortunate that the recent surge in scholarship on the effects of social networks, risk management, and natural resource utilization has not more directly engaged the work in anthropology and sociology on material exchange and moral economies , though some exceptions exist . In addition to providing households with needed material goods especially food, exchanges between households create networks of reciprocity, trust, and support . Hunt has distinguished between exchange and transfer, where exchanges involve reciprocity and transfers do not necessarily . In the context of this study, transactions involve the expectation of reciprocity, as we will describe below, and therefore we refer to them as exchanges throughout the paper. In East Africa, pastoralist and agro-pastoralist societies provide vibrant examples of how social networks and material exchange are integral to social/ecological systems and natural resource management . Furthermore they offer productive comparisons with strictly agrarian societies for which mobility and common property management are less common risk management strategies. Exchange within pastoralist groups can take many forms and often supports the persistence of existing land use practices. While exchange traditions are institutions driven by many factors, including the forces of cultural inertia and history , perhaps the most common function of exchange articulated in the literature on pastoralist communities is that they are mechanisms to pool risk and promote security and stability in the face of uncertainty . Households may form networks with each other to insure against loss from a number of concerns including drought and disease. Another function of exchange networks is their role in promoting herd and family development . Through various types of networks, an individual can acquire wives for himself or his sons and diversify the species in his herd. And through the development and growth of his herd and his family an individual can reduce the chances that future losses will require assistance from his network. In this way, exchange networks serve to promote the independence of the household at the same time that they provide the promise of support in times of need. Despite the ubiquity and functionality of exchange networks in contributing to ex ante risk mitigation strategies and ex post risk coping strategies, few studies have examined the effect of LD on social networks of exchange. LD itself is understood as a means by which households can manage their exposure to risk and cope with adverse circumstances . This raises questions about the relationship between LD and social networks of exchange in agro-pastoralist societies specifically and about functional redundancy in social networks more generally. --- Livelihood diversification Defined simply, LD is the "process by which rural families construct a diverse portfolio of activities and social support capabilities in order to survive and to improve their standards of living" . The effect of LD as an instrument of risk management has been framed in the language of "push" and "pull" factors wherein households facing adverse circumstances are pushed into LD and households responding to opportunities are said to be pulled into LD. Functionally, these justifications are closely aligned with those that shape decisions to participate in social networks of exchange, yet little scholarship has examined this. Much of the literature on LD has focused on its determinants with fewer studies examining the role of diversification as a predictor, or independent variable . The literature on LD among pastoralists and agro-pastoralists follows these trends. While many studies have focused on the drivers of LD, including land privatization , NGO sponsored development , education , market integration and biodiversity conservation , less research has been done on outcomes driven by LD among pastoralists. Important exceptions to this include research on the effect of LD in shaping family size and livestock management activities . As noted above, few studies have investigated the relationship between social networks of exchange and LD. Cinner and Bodin have used social network analysis to examine how the structure of social networks of natural resource users affects patterns of LD. They found that diversified resource users, connected through networks that span occupational fields, tend to specialize as development occurs, but that communities remain economically diversified. Many opportunities, however, to examine these and other issues remain. Following the opportunities to integrate the fields of study on social networks and LD, this study seeks to understand the character of IHE among Maasai households in Simanjiro District, northern Tanzania. Furthermore, it seeks to understand how IHE has changed and how LD at the household level is associated with IHE. Along these lines, the study investigates two research questions : RQ1. What are the primary instruments/mechanisms of IHE? How are they used? How are they changing? RQ2. What is the effect of LD on IHE, controlling for other factors? --- STUDY SITE Simanjiro District in northern Tanzania is well suited to investigate the relationship between LD and social networks. The communities in Simanjiro are ethnically homogenous, have traditionally maintained elaborate networks of exchange , and are in the process of diversifying their livelihoods . The district, which is located within the Tarangire-Manyara Region, is one of the most diverse grassland ecosystems on the planet and has been the focus of intense biodiversity conservation efforts for decades. A central feature in the region is Tarangire National Park , which lies immediately to the west of Simanjiro District. Before the park was established, the areas that are now Simanjiro District and TNP comprised portions of the traditional territory of the Kisongo Maasai . This group's economic activities traditionally centered on transhumant pastoralism, a culturally engrained activity well suited to this area's semi-arid climate and high degree of rainfall variability . In the past few decades, however, Maasai throughout East Africa have begun to adopt agriculture for various reasons . More recently, some Maasai have begun to adopt other livelihood activities including labor migration to urban centers, local non-farm employment, and sharecropping . Much of the research on this area has focused on the social dynamics of biodiversity conservation . In fact, this study is part of a larger study of the effect of TNP on community development and livelihood change in Simanjiro District. Six ethnically Maasai communities are included in the study . Communities were originally selected to highlight proximity to TNP. Two communities are located adjacent to the park, two are near the park but not adjacent, and two are located far from TNP. Earlier findings from the larger study have shown a positive association between LD and proximity to TNP . These findings are consistent with other studies that show diversification to be a growing trend among the Maasai and that biodiversity conservation may be driving it in some cases . Analyses for this paper will seek to expand on these findings by examining the association between LD and IHE as will be explained below. --- METHODS Multiple methods of data collection and analysis were integrated to address each research question. The primary methodological approaches utilized were semi-structured group interviews and a structured survey of households. These data collections tools are well established in the social sciences. We will first describe our use of qualitative group interviews and then the implementation of a structured household survey. --- Data collection Semi-structured group interviews were conducted with community members, administrators, and leaders in each community to: assess the character and causal processes of IHE and other aspects of Maasai life; inform the development of a household survey instrument to measure the incidence of IHE and other household characteristics; and yield information on the monetary value of livestock and agricultural products to facilitate the conversion of survey measures into monetary measures for analysis. This method allowed for open discussion around broadly framed questions about household economics and IHE as well as more targeted questions about seasonal market prices. Participants were selected for their daily participation in livestock and farming activities and knowledge of current and historical use of IHE transactions. The interviews solicited information on a range of topics including: how transaction types are different from each other; how and when each type of transaction is used; how social organization and the age-set system2 affect patterns of exchange between households; how new economic activities and material goods have been incorporated into these exchange processes; and how current trends are different now than they were in the past. All group interviews were conducted by the first author with the assistance of 1 or 2 Maasai assistants/translators. To collect quantitative data on the incidence of IHE for use in statistical analyses, a structured household survey was implemented with 36 households in each of the 6 study communities . Data were collected on issues that included: the number and type of transactions with other households; the item exchanged; the terms of repayment , the purpose of the exchange, the age-set of the other party, the relation of the two parties ; and basic household demographic and economic variables. Without access to a census on which to base a strictly random sample, we sought to sample: households from different community sub-villages ; household heads from each of the major age-sets; and households representing a range of wealth statuses . This approach, which Bernard refers to as quota sampling, reflects our best efforts to draw a representative sample. Local leaders were enlisted to assist in the identification of households meeting these sampling criteria. By nature of the data collection strategy, these data provide extensive information on the respondent and his engagement with other parties 4 . They provide limited information, however, on the other parties with whom transactions were conducted. Therefore these data preclude the elucidation of several aspects of the larger exchange network structure. They do, on the other hand, provide robust information on the extent to which the respondent is engaged in local social network of exchange. This was done as a matter of necessity and intention. First, respondents were disinclined to reveal detailed information about the parties they exchanged with as many transactions are meant to be private -details about the transaction itself, however, were not off-limits. Second, by design, this study sought to examine the association between household LD and engagement in IHE. As such, the data communicate little about the characteristics of the network itself and much about individual membership in the network. In addition to information on current IHE, the survey collected information on the respondent's perceptions of how the incidence of IHE in the present compared to the past. In the case of perceptions of the past, questions were asked about the past generally and about the specific period around 2002-2003. This specific time period was a relatively good year for rain preceded by two poor years, and therefore resembled the recent climatic conditions at the time the survey was conducted in 2010. Lastly, to calculate household measures of livelihood diversification, data were collected on: livestock holdings including breed types, gender and age; purchases and sales of livestock in the previous 12 months; land allocation; area of land farmed; species farmed; farming techniques; agricultural yields in 2010; non-farm employment by household members; remittances to the household; and household demography . Surveys were conducted by trained Maasai enumerators between September and December, 2010. --- Data analysis Our analysis of the dynamics of IHE proceeded in several steps as described below. The first set of qualitative analyses describe the primary mechanisms of exchange and how they are used, how they are changing, and how they are integrated into the social and economic lives of local people . The second set of analyses use regression models to understand how LD is associated with: the utilization of these exchange mechanisms; and perceptions of their use compared to the past . Description of IHE-We conducted content analysis of group interview responses to describe the primary instruments of exchange, how they are used, and how they are changing . Specifically, we inductively coded six group interview responses using qualitative analytical software . These interviews focused exclusively on IHE. Beyond identifying the basic structure and function of exchange mechanisms, coding focused on linking the exchange mechanisms to larger social and economic processes, such as household demographics, including family creation and growth, and herd management and development -issues that are closely intertwined. Our interpretation of these interview responses was strongly supported by insights gained through other group interviews that focused on different aspects of Maasai society, including issues related to household and community social and economic processes. To provide additional context, basic descriptive statistics of IHE types and their characteristics are also displayed below. Regression models-To examine the association between LD and: current utilization of IHE; and perceived incidence of IHE compared to the past , Poisson and multinomial logistic regression models were estimated, respectively. Measures of current IHE utilization included: total number of loans ; total number of restocking events ; total number of gifts ; and total IHE 5 . Poisson models are used in these cases because each dependent variable is a count variable. Measures of perceived incidence of IHE compared to the past included perception of relative frequency of: loans; restocking; and gifts. Multinomial logistic regression was used because households provided a categorical response indicating declining, stable or increasing frequency of these activities. "Less common" is used as the reference category. LD is represented by two variables: % of Income from Livestock, and a Herfindahl index . Given that the Maasai are traditionally pastoralists, households that are more diversified tend to have a lower percentage of total income coming from livestock than households that are less diversified. This measure is well established in the literature on LD in pastoralist communities . The second variable, a Herfindahl index, is similarly a measure of concentration . This index, which is often used to measure competition in economic sectors and diversification within firms , is calculated as the sum of the squared percentage of income per source of total household income. Sources of income include income from livestock, agriculture, petty trade, wage labor, small business activities, mining, and proceeds from leased land6 . Squared terms of each measure of LD were included in the models to test for nonlinearity. In total, we estimated four specifications of our models: a linear measure of % of income from livestock; linear plus squared terms of % of income from livestock; a linear measure of the Herfindahl index; and linear plus squared terms of the Herfindahl index. Controls included characteristics of the household head and of the household . Our small sample of communities limits our ability to statistically address contextual effects on IHE. Despite this limitation, we were able to add a control for proximity to TNP, which has been linked to LD in this area . Descriptions and means of the variables used in each set of regressions models are presented in Table 1. All models are adjusted for clustering at the level of the community , which corrects for any community-level correlation arising from the clustered sampling strategy. A final consideration with our modeling is the nature of the relationship between IHE and livelihood diversification. We argue that LD can be considered as exogenous to IHE in this context because LD has been largely driven by changes in the macro-scale political economy including land tenure insecurity and privatization , increased integration with markets and education , and increased exposure to the diets and livelihood strategies of other ethnic groups . Furthermore, in the qualitative findings below, we identify no mechanism by which traditional practices of exchange could have led to the widespread adoption of novel and non-traditional livelihood activities such as agriculture. --- Strengths and weaknesses of the approach The methodological approach described above has several strengths. First, mixed methods of data collection and analysis provide detailed qualitative information about IHE and how and why they have changed, as well as quantitative data on the present use of IHE and perceived incidence of IHE compared to the past. Many studies of social dynamics focus on qualitative descriptions of causal mechanisms and change or they focus on incidence of phenomena and statistical associations. Few are able to do both. Second, this study uses perceptions of change to get at historical conditions and therefore can comment on longitudinal change despite the use of cross-sectional data. This particular strength is supported by the consistency of the qualitative accounts of change and the quantitative measures of perceived change. Third, this study examines two separate measures of LD. The central weaknesses of this approach are that the sample size is small, the sampling strategy was not random, and the study was cross-sectional. Mean measures of household wealth obtained in this study, however, are consistent with measures from much larger studies of Maasai households in Tanzania that utilize random samples , suggesting that this sample is not necessarily skewed with regards to wealth. --- FINDINGS Descriptions of inter-household exchanges The primary mechanisms by which households in the study area exchange material goods are lending, restocking, and gift giving8 . In addition to being identified through informal interviews early in the data collection process, these general categories are established in the literature . Here we will present findings from qualitative group interviews about how each mechanism is used and how it has changed from the past. Also, basic descriptive statistics are presented for each mechanism. Lending-Loans are contractual agreements based on trust and arranged verbally between two parties whereby a material good is provided to the borrower by the lender and a date and form of repayment are specified. Loans are private arrangements between the parties and are only extended in the event that the borrower is facing a particular problem. That is, loans are not extended for the expressed purpose of speculation by the borrower. There are two general types of loans: loans where the item transacted is kept and put to use by the borrower, and loans where the item is sold to generate cash with which to address the problem. Typical problems that may drive a borrower to seek out a lender include: herd losses from drought, disease, and/or predation sufficient to inhibit the provision of food to the household; family medical emergencies requiring expensive care; and other problems requiring cash. Currently, as in the past, loans between households are generally given and repaid in the form of livestock. In these transactions, repayment typically includes the principle plus interest. Consequently, animals of lesser value are loaned and those of greater value are repaid. Because of their capacity to reproduce, female animals are more valuable than males. Male animals, therefore, are often given as loans and female animals are used to repay the loan. For example, a loan of an ox would be repaid with a heifer, because a heifer is more productive and therefore more valuable. Similarly, a female sheep would be used to repay a loan of a ram. In other cases, a loan of a goat or sheep may be repaid with a cow if an appropriate goat or sheep is not available. This creates an incentive for the lender to take on the risk of lending and can also serve as a strategy for herd development. In one group interview, respondents indicated that because loans of male goats can be repaid with immature oxen, one can "build a herd using goats." In other words, by focusing on goats, which reproduce quickly, a household head can subsequently expand the diversity and value of his herd by extending loans to others. Furthermore, since the acquisition of wives in Maasai society is dependent on the transfer of bride-wealth from the groom's family to the bride's family, traditionally in the form of livestock, herd growth is a necessary precursor to family growth. For the borrower, loans are an important tool to maintain family affairs in the face of hardship. For most subsistence societies, problems often require cash . For Maasai, who commonly store wealth on the hoof, problems often require the sale of animals to raise cash. If the sale of animals would render the household foodinsecure, then a loan may be necessary. In this case, the borrowed animal would be sold, and the cash used to address the problem. Restocking-Restocking is similar to lending in that it has traditionally been used when a household faces a problem, generally when a household has lost most or all of its livestock to drought, disease, or predation and the household head can no longer provide for his family. Unlike loans, however, restocking involves the transfer of material goods from multiple individuals to the troubled household making this type of exchange more public than lending. Furthermore, items are not loaned, but gifted, and therefore repayment is not involved, though recipients are expected to contribute to restocking efforts for other households when future needs arise. Smaller restocking events, typically for smaller families, may be taken care of within the homestead9 of the receiving household. With larger households, however, leaders typically organize restocking events and contributors are recruited from within the larger clan10 . Group interviews with participants noted that the primary purpose of restocking was to support and provision the family, especially children. In some cases, household heads may liquidate the household herd to support unhealthy behaviors, particularly drinking. In a case like this, a clan member would be appointed to oversee the restocked animals. As one respondent stated, "the clan wants to take care of children, not drunks." In some cases, restocking is used to provide animals to households with unmarried sons who are seeking wives but lack sufficient bride-wealth. In a situation like this, not having a wife is considered a problem and restocking is therefore appropriate -though only for the first wife. Individuals cannot receive restocking support to acquire subsequent wives. Given these examples, it can be seen that, for the receiving party, restocking is an instrument that supports both the maintenance of the household and even its establishment. Gift giving-Gift giving is the most versatile of the three exchange mechanisms and is different from lending and restocking in many ways. Perhaps most importantly, unlike lending and restocking, which traditionally are only used in the event that the receiving party has a specific problem, gifts can be given for a number of reasons which include but are not limited to addressing a specific problem. Other reasons for giving gifts are centered on establishing friendships between individuals. In Maasai society, friendships are generally solidified through the transfer of a gift from one party to another. Once established, friendships extend and strengthen an individual's social network. Social networks, which may be comprised of family, clan, and age-set members as well as friends, are the foundation of a household's support system and the first people to which a household will turn when it confronts problems and is in need of assistance. In this way, gifts can be seen as tools to extend the household's safety net. Unlike loans, gifts are very public forms of exchange, with parties generally giving each other nicknames that serve as reminders of the gifts. Typically, these nicknames are simply the name of the item gifted and replace birth names in everyday interactions between the parties. The nicknames are meant to demonstrate publicly the formality of the friendship and often they will be passed down to the children of the parties. Gift giving is a common and even expected tool of social networking. As one respondent noted, "It's not good to call someone from your age-set by his name. You need to give the gift…" and use the nickname. Another distinguishing characteristic of gifts is that they can be either solicited or unsolicited. In the case of unsolicited gifts, one individual will offer a gift to another individual. As noted above, the individual receiving the gift may or may not have a problem that needs to be addressed. In the case of solicited gifts, an individual will ask another individual for a gift and upon receipt of the requested gift will invite the giver to "follow the gift". This means that the giver is invited to come to the friend in the future when he needs or desires a gift and the receiver will be there to reciprocate. Even with unsolicited gifts, the expectation is that the giver will, at some point in the future, "follow the gift" and ask for something. Interview respondents said that gifts are very much like loans except that there is no contract with gifts as there is with loans. Common gifts include various species of livestock, carved sticks, and blankets. Even daughters are giftedwith one man's daughter becoming another man's wife11 . Given their flexibility, it is not surprising that gifts are used in wide variety of situations. Elders may use gifts to reward the obedience of younger generations. For example, an elder may ask a young person to move the elder's herd a long distance to find water or to perform some other task. The youth honors the elder by obeying and may be given a gift to mark their relationship. A similar tactic may be used by an elder who wants a certain young man to marry his daughter in the future. In this case, the elder may ask the youth for a gift "to see his obedience first," as one respondent put it. This use of gifts to prospect for sons-in-law and facilitate marriage is common. In fact, elders may extend gifts to each other in the hope of arranging a daughter for one of their sons. In some cases, gifts are used to prospect for children. In the event that a household head is sterile he may ask his brother to lay with his wife. Any resulting children will belong to the head and for his service the brother will typically be given a heifer as a gift. In other cases, gifts are used to establish strategic relationships with others to support future herd maintenance and growth. When a gift is given, however, it's not always clear what reciprocal gift may be coming in the future. In some cases an individual may give one cow as a gift at one point and receive multiple cows in the future. But, as was noted above, gifts are not contracts. As one community member put it, "you have to follow every gift -but it's not a contract. You could follow it and get nothing." Changes from the past-The descriptions of lending, restocking, and gift giving offered above present an overview of these mechanisms and how they have traditionally been used. Here we will present findings from qualitative group interviews on how IHE have been changing in response to the increasing incorporation of agriculture into household economic activities as well as the increase in development more generally. The rising dependence on agriculture among the Maasai over the last few decades has affected IHE in a number of ways. According to respondents, the inclusion of agricultural products in IHE began as soon as cultivation became common. Gifts and loans of maize are now used to move harvest output from households with surpluses to households with shortages. An individual may have a productive year on his farm while others do not and using loans and gifts he can distribute his surplus maize to households in need. Then, in the future, when his farm doesn't perform well, he has people to go to for help. This is particularly helpful given the highly variable spatial distribution of rainfall in this area within and between years. The use of agricultural products in Maasai lending and giftgiving culture does vary in notable ways from more traditional exchanges. In the case of loans, interest payments are not typically included in repayment as is the case with livestock. When we asked why this was the case, one respondent said, "we don't slaughter maize." Furthermore, with agricultural gifts, nicknames are not used following the exchange as they are with other types of gifts. Changes associated with development have brought new opportunities and constraints that have affected the use of IHE. Traditionally, restocking and loans were reserved for problems or crises only. One respondent pointed out that "you can't get a loan or restocking if you don't have a problem." But now in some communities lending, restocking, and gift giving are being used to help households capture opportunities -especially educational opportunities. Students who have passed their primary school exams and are eligible for secondary school face stiff fees. To cover school related expenses, households may be forced to sell many animals. This burden is too great for some families and many students forgo secondary education for lack of funds. In some cases, however, friends, clan members, and others have supported the family through restocking, gifts, and/or loans so that the student could continue his/her education. This is a relatively new, uncommon phenomenon but seems to be more common in communities near TNP. School construction and the attending increase in student enrollment , which in some cases is supported by exchange mechanisms mentioned above, are introducing new constraints on exchange networks. For example, young women, many of whom are enrolled in school and are embracing aspects of the developed world, do not want their fathers to decide who they will marry. Describing the challenges that he faces in asking for gifts one father said, "I can't always give daughters now because they want to choose." According to interview respondents, this has undermined gift giving culture. Now that young people can't expect a wife in return, elders say that is it harder to get them to obey. "Obedience disappeared!" For these and other reasons, group respondents felt like gift giving was less common than is used to be. Issues of "obedience" are closely related with more general concerns regarding trust in several of the study communities. In group interviews, respondents noted that people do not trust each other now as they did in the past. They attributed this to a number of things including population growth and an increase in the incidence of loans that are not repaid -"there are some cheaters now". It is more difficult now, they claimed, to have faith in a borrower and therefore some loan requests are simply denied. In the past, however, people didn't refuse loans. People "were just waiting for the cow's stomach". That is, they were freely extending loans and waiting for cows to give birth so that the loan could be repaid. In the past, respondents claimed, you didn't need to know people well to lend to them. Now, friendship is often a necessary prerequisite for lending. Ultimately, people are more cautious now and only extended loans to people they know well. Descriptive statistics for loans, restocking and gifts-Our survey respondents reported data on 846 IHE transactions. Table 2 presents descriptive statistics for these transactions. Statistics are reported for each transaction type , stratified by whether the transacted item was given or received and stratified by percent of income in the form of livestock for the respondent's household. For each combination of transaction type, transaction direction and income from livestock strata , the number and percent of each transaction item is presented along with the average age-set direction . In the case of loans, the average payback period is also reported. And in the case of gifts, the percent of transacted items requested and items for a problem are also each reported. Several general findings are evident here. First, livestock comprise the great majority of transactions for each transaction type, although maize is not uncommon. Second, the average payback period for loans is 7-11 months, which is consistent across strata. Third, gifts are more often given by younger age-sets and received by older age-sets. Fourth, restocking is typically given by older age-sets. Fifth, clear age-set directions are not apparent in the case of loans. And sixth, households classified as having a higher percent of their total income coming from livestock are engaged in IHE the most. --- Predictors of current IHE & perceived trends The results for the regression analysis of the association between LD and IHE are presented in two tables and two figures, first for current use of IHE followed by perceived changes. Our discussion below focuses on the effects of LD, but it is worth noting that the effects of the control factors are largely consistent across outcomes and consistent with expectations: participation in and perceptions of increases in IHE are typically more common among larger and more educated households with older heads and less access to agricultural land. As expected, measures of LD had significant effects on the use of IHE when controlling for other factors . Beginning with specifications 1 and 2 13 , the effect of % of income from livestock on IHE types is significant and non-linear in the case of loans and restocking, and significant and linear the case of total IHE. With specification 4 , the effect of the Herfindahl index is significant and non-linear for each dependent variable. Taken together the findings presented in Table 3 reveal that the effects of LD on IHE are largely negative but that the relationship is nonlinear, with the steepest decline in IHE as income moves away from dominance by livestock. The chief exception to this pattern is restocking, where intermediate levels of % of income from livestock are associated with the highest levels of engagement in restocking. Models that disaggregate total IHE values into values for given and received tell a similar story . To further clarify these relationships, Figure 2 presents predicted values of numbers of exchanges by exchange type using the nonlinear specification of the Herfindahl index, which provided the best overall fit. This confirms that participation in IHE is lowest at intermediate values of LD. However, in the range of the Herfindahl index values where these households are concentrated , the relationship is largely positive. Measures of LD also had significant effects on perceived trends in IHE when controlling for other factors . In specifications 2 and 4, the effects of % of income from livestock and the Herfindahl index on perceived trends for loans and restocking were significant, non-linear, and similar to each other. Figure 3 presents predicted probabilities of perceiving IHE as "as common" or as "more common" in 2009-10 compared to 2002-03 for loans and restocking, which had significant nonlinear effects from the Herfindahl index. The lowest odds of ranking loans as more common at the time of the interview compared to 2002-03 were found at intermediate levels of diversification. In other words, moderately diversified households are more likely to view loans as declining rather than increasing in use. The relationship between LD and perceived trends is different in the case of restocking. The lowest odds of ranking restocking as more common than the past were found at the highest levels of diversification . However across the range of Herfindahl values where the sample is concentrated , both loans and restocking were more often perceived as "more common" by non-diversified households with high Herfindahl values, consistent with the positive linear effects in S1 and S3. Thus, the results on perceived IHE change paint a consistent picture with the previous results of participation: the least-diversified and most livestock-dependent households are mostly likely to use IHE and most likely to perceive that its use has increased over time. --- DISCUSSION The qualitative results of this study provide evidence that: IHE, in the forms of lending, restocking, and gift giving, are used by Maasai households to spread risk, respond to shocks, create and strengthen social networks, support herd and family development ; and the ways in which households are using IHE are evolving to incorporate new opportunities associated with agriculture and education . These findings, also elucidate a set of exchange mechanisms that have been under-examined in the ethnographic literature on the Maasai . In several distinguishable ways, IHE have been central to households' strategies to insure themselves against catastrophic loss , to manage smaller problems , and to promote marriage and family development through important intergenerational relationships 14 . Furthermore, the centrality and versatility of these mechanisms as tools to facilitate social and economic endeavors is exemplified by ongoing adaptations in their use. For example, the incorporation of agricultural products in IHE, which followed immediately after the adoption of agriculture, according to interview respondents, helps to mitigate the risks associated with rain-fed agriculture in an area characterized by high rainfall variability. Unable to move their farms to where the rain falls as they do with livestock, households move harvests, through exchange networks, to where rainfall was limited by transferring surplus harvest to households with low harvests. Similar innovations are evident in the growing use of restocking and loans to support educational opportunities. And yet, despite these innovations, the use of IHE is reported to be on the decline throughout the study area. The quantitative results of this study provide strong evidence that both the incidence of and perceived trends in IHE are significantly negatively associated with LD at the household level. Indeed, model specifications using two separate measures of LD communicate a similar story. Only in the case of restocking do these two measures offer different stories . As noted above, other predictors, specifically age, education, family size, and land allocation were consistent across models and point to other factors that shape engagement with IHE. It is not surprising that older heads and those with larger families would be more engaged in traditional IHE. Similarly, it's not surprising that access to more agricultural land would be associated with less engagement. Conversely, the effect of education on IHE, which does not vary depending on whether the exchange was given or received , is less clear and should be investigated further. Along these lines, future studies of IHE among the Maasai and other pastoralist societies could be improved in multiple ways. First, sampling a larger number of communities would allow a more thorough investigation of contextual effects. Second, gathering quantitative data on positive and negative shocks to the households would improve our understanding of the contexts in which IHE are used. And third, finding ways to reduce reporting bias , perhaps through ethnographic approaches to estimate under-reporting. Despite the limitations noted, our qualitative and quantitative findings, taken together, offer strong support for the hypothesis that LD and IHE are inversely related . This relationship was noted in several group interviews with community members, but was elaborated most clearly during an interview about restocking on July 22, 2010. At one point in the interview, the first author asked the question "Is restocking different now from what it was in the past, and if so, how?" The group asserted that there have been no changes in the mechanics of restocking, but that in the past it was used more frequently. In the past, they noted, people were poor and they were depending exclusively on livestock. Today, they said, people have more options. People are engaged in farming, or in wage-labor. A household that has lost many animals, they described, might have farm proceeds to support themselves -so there is no need for restocking. Ultimately these findings outline a story of adaptation wherein a traditional system of exchange is, at once, evolving and declining. While the cross-sectional nature of this study precludes a more robust examination of change, descriptions from group interviews and data on perceptions from the household survey tell a consistent story of IHE decline. This story of decline, along with the inverse relationship between IHE and LD found here, is well aligned with studies that have detailed the rise in LD among the Maasai in recent decades . Furthermore, these findings add to the literature on the determinants of social networks of exchange in agrarian societies and respond to calls for more research on the social context in which exchanges are used . The transition from one form of risk management to another holds several implications for the growth, development, and resilience of households and communities. The trend towards LD and individualization in pastoralist societies can be see an effort to protect the livestock economy , secure land tenure , and expand incomes for the purpose of engaging more with the cash economy . Furthermore, this trend may reduce certain risks, and add others. Diversified households may be more able to manage high incidence / low severity shocks , but less well prepared to manage low incidence / high severity shocks . Similarly, where community cohesion is reduced by disengagement in IHE, the ability to mobilize and act collectively in the face of communitylevel shocks may be reduced as well. This may be especially germane in the case of societies that have traditionally managed commonly held resources -and societies that face repeated external shocks from markets , climate-related events and/or protected areas . In other words, it may be that improved household development and resilience to small shocks in the short term is being paid for by reduced household and community resilience to larger shocks in the longer term. This calls into question the mutability of these changes. One debate in the literature on LD among pastoralists is whether LD is cyclical. Arguing that it is, Little et al. suggested that LD is linked to individual life histories and cycles of family development. Others have argued that process of LD among pastoralists is best understood as linear and permanent . Our sense, which is based on arguments from these studies as well as extensive fieldwork in the study area, is that LD is indeed unidirectional. So -if LD is linear and negatively correlated with IHE, what new questions do these findings raise regarding the structure and function of social networks more broadly? --- Social network transition The findings presented here, taken alongside the literature on LD among East African pastoralists described above, provide some support for the hypothesis that lower levels of IHE represent a new normal -a watershed in this social network of exchange -and that increased livelihood diversification and reduced IHE are part of the process of transition from an old regime to a new one. Conceptually, this argument proceeds in three basic steps: households diversify; households change the ways they use a social network; and households reduce their engagement with their traditional social network. Prior to the transition, households are characterized by low levels of LD and high levels of IHE. Following the transition, however, this profile is inverted with households exhibiting higher levels of LD and lower levels of IHE. This hypothesis focuses on the network's density, not its structure, and raises further questions. What can be the implications for a social/ecological system associated with a social network transition of this nature? There are few studies in the literatures on social ecological systems, livelihoods, or pastoralism that offer insights into this question. Robert Putnam's book, Bowling Alone , however, on the evolution of community in the U.S. during the twentieth century, draws on numerous studies of social networks and raises several important issues germane to this study. Here we will briefly focus on two: the distinction between bridging and bonding social capital; and the capacity for collective action. A commonly held notion in the literature on social capital is that social networks confer social capital on their members . It follows, therefore, that different types of networks, or connections within a network, offer different types of capital. "Bonding" social capital is a form of capital conferred by network connections that are focused inward within a society or group of people, whereas "bridging" social capital is conferred through connections that are directed outward. Putnam , who credited Gittell and Vidal with the earliest use of these labels, described bonding and bridging in the following way: Some forms of social capital are, by choice or necessity, inward looking and tend to reinforce exclusive identities and homogenous groups… Other networks are outward looking and encompass people across diverse social cleavages… Bonding social capital is good for undergirding specific reciprocity and mobilizing solidarity. Dense networks in ethnic enclaves, for example, provide crucial social and psychological support for less fortunate members of the community, while furnishing start-up financing, markets, and reliable labor for local entrepreneurs. Bridging networks, by contrast, are better for linkage to external assets and information diffusion… Bonding capital is, as Xavier de Souza Briggs puts it, good for 'getting by,' but bridging social capital is crucial for 'getting ahead. '" . Given this distinction, it can be argued that the Maasai institutions of lending, restocking, and gift giving described in this study represent bonding connections between households. Findings from group interviews that IHE are reciprocal and meant to promote solidarity within and across age-sets, and support less fortunate members of the community support the notion that connections are bonding connections. Furthermore, data from our structured survey show that Maasai households conduct IHE almost entirely with other Maasai households which serves to create an exclusive, dense network that is inwardly focused. Framed in terms of bonding connections, the trend towards fewer IHE should be investigated. For example, what are the implications of fewer bonding exchanges? One hypothesis is that reduction in bonding connections, which are part of the glue that holds close-knit communities together, would yield greater household independence and, correspondingly, reduced capacity within the community to act collectively. Like other pastoralist and agro-pastoralists, the Maasai have traditionally managed risk collectively and avoided collective action dilemmas, like the tragedy of the commons , through strong institutions including the age-set system, clan membership, and other social networks founded on exchange and reciprocity . Together, these institutions promote an atmosphere of trust and interdependency within communities that is central to collective action. It follows, therefore that as these institutions diminish, so too will communities' capacities to avoid free-rider problems and associated negative outcomes , including land conversion and degradation -which can introduce risk at multiple scales. An alternative, but not necessarily mutually exclusive, hypothesis is that a reduction in the number of IHE frees up, or releases, material resources for use in other types of exchanges and/or connections; especially bridging connections with individuals or groups outside the community. While this study has focused on changes in traditional bonding networks, and therefore cannot address changes in bridging connections at the household level, there are reasons to suspect that bridging trends are becoming more common. Other studies from this area, show that several communities have begun actively recruiting financial resources from external international organizations, in some cases leveraging their close proximity to TNP to encourage tourism and conservation agencies to build education and water infrastructure in the area . It's unclear to what extent households themselves are engaging in bridging behavior. However, observed increases in school construction and school enrollment in the study area suggest, along with evidence of livelihood diversification, that local households are increasingly cultivating new forms of human capital that would facilitate growing integration with external individuals, institutions, and organizations . --- Household demography and land use A final consideration that we will address briefly here is that, given the numerous and complex ways in which IHE are integrated into marriage and household growth, herd development, and the persistence of agriculture, a change in IHE may contribute to dramatic long-term changes in household and community demography, social organization, and land use. While many studies have linked demographic, social, and land use change to changing livelihoods and integration in the market economy , few have focused on the role of exchange networks in demographic shifts. Studies of Maasai demography are themselves scarce ). However, circumstances associated with changing use of IHE, which include the waning use of daughters in reciprocal exchanges, the growing use of exchanges to support education, reduced access to loans to address problems, and the incorporation of agriculture into exchange mechanisms may ultimately contribute in important ways to changes in nuptiality and total fertility, increased school enrollment , wage labor and migration, and land conversion to agriculture, respectively. Certainly, the decline of IHE identified here raises concerns about households' and communities' abilities to confront future challenges including perennial struggles such as drought and disease . But it also raises concerns about how Maasai will confront new challenges associated with climate change, a growing global concern for environmental conservation, and their own increasing engagement with a rapidly developing world. It may be that the persistence of social networks of exchange, albeit at a level reduced from earlier times, combined with the benefits of individual livelihood diversification and the development of bridging relationships allows for the flexibility to meet these challenges. Adult Equivalents is a measure of a group of people expressed in terms of standard adult reference units, with respect to food or metabolic requirements. An adult male serves as the reference adult with other categories measured as fractions of that reference: adult male = 1 AE; adult female = 0.9 AE; male/female 10-14 years = 0.9 AE; male/female 5-9 years = 0.6 AE; infant/child 2-4 years = 0.52 AE. b --- Map of study area Tropical Livestock Units are defined here as: 1 adult zebu cow = 0.71; adult sheep/goat = 0.17 . c Milk used and sold, or milk off-take, was calculated from our herd demographic data . Our resulting estimate for average off-take per AE per day, which is both a function of calves and household per capita wealth , for our sample was remarkably similar to observed off-take from the study area in 2005-2006). The value of off-take was calculated from observed prices of milk in the study area, also from Sachedina . --- Supplementary Material Refer to Web version on PubMed Central for supplementary material. --- --- Baird and Gray Page 32 Table 2. Descriptive statistics of IHE. 18) 4 1 16 in other, n 4 3 3 ( 18

In the developing world, traditional social networks of exchange and reciprocity are critical components of household security, disaster relief, and social wellbeing especially in rural areas. This research asks the question: How are traditional social networks of exchange related to emerging household strategies to diversify livelihoods? Within this context, this study uses a mixed methods design to examine the character of inter-household exchanges of material goods (IHE) and the association between IHE and livelihood diversification, in ethnically Maasai communities in northern Tanzania. Findings show that IHE are both evolving and declining and are negatively associated with livelihood diversification.

Introduction Health equity has been defined as "the state in which everyone has the opportunity to obtain full health potential and no one is disadvantaged from achieving this potential because of social position or any other socially defined circumstances" [1]. The Ministry of Health in New Zealand recognises that people have differences in health that are not only avoidable but unfair and unjust [2]. The underlying causes of health inequity are largely located outside of the typically constituted domain of "health". However, the end result is a disproportionate burden of ill health in populations that face social, economic, cultural and political inequities. Equity recognises different people with different levels of advantage require different approaches and resources to produce equitable health outcomes [2]. In 2019, a cluster of people with pneumonia of unknown aetiology were identified in Wuhan, China [3] and by January 30 the World Health Organization declared the coronavirus disease 2019 outbreak as a Public Health Emergency of International Concern [4]. In response to the COVID-19 pandemic, in April 2020 the Government of New Zealand introduced a four-level alert system. At Alert Level 2 and higher, the Government recommended that people at higher risk of mortality from contracting COVID-19 should stay at home. Those at 'high risk' included older people and those with underlying health conditions [5] which are prevalent in the older population. During the pandemic, some older people in NZ will have spent more than 200 days confined to their home. In many cases, unpaid kin and non-kin caregivers supported older people by providing care and assistance with activities of daily living and home health care. In this study we use the term 'unpaid caregiver' to describe someone who provides care and support primarily because of a personal kin or non-kin relationship with the care-recipient. We do not use the phrases 'informal care' 'care partner' or 'carer'. The former contributes to the invisibility of unpaid caregivers in society as it conveys the impression that roles are unofficial and 'not essential' [6], while the latter do not clearly distinguish unpaid caregivers from paid care providers. Caregiving in the community is often under-appreciated [7]. However, global health and social care systems are so reliant on unpaid caregivers that they constitute an essential workforce [8,9]. In the international response to control COVID-19 transmission, unpaid caregiving has, and continues to be, the 'backbone' of health and social care provision in the community. However, the voices and stories of family caregivers have been invisible, and our knowledge of the successes, rewards, and challenges faced by those providing care to older people is limited. To date, articles assessing the situation of caregivers during COVID-19 have tended to focus on individual psychosocial outcomes such as depression [10], stress [11], burden [12,13], suicidal tendencies [14], substance abuse [14], and psychological distress [15]. This research intends to raise the profile of unpaid caregivers providing essential support to older people, including those living with dementia, by recognising their significant social role during the COVID-19 pandemic in NZ. The research will generate new knowledge by exploring how family caregiving roles, access and use of resources changed. It will identify positive aspects of caregiving alongside unmet needs and challenges. The research will put knowledge into action by collating and co-designing resources for family caregivers to support their care analysis included in participant information forms) and sensitivity . These restrictions have been ratified by the Auckland Health Research Ethics Committee at the University of Auckland. Data will be available from AHREC on reasonable request. Data will be located in a controlled access repository at the University of Auckland. of older people. Pooling knowledge about caregiving during COVID-19 with international study teams , regarding caregiving in indigenous and minority populations, in the context of rurality and caregiving for people living with dementia, will facilitate cross-national knowledge transfer. Mapping responses in different countries aimed at supporting caregivers during the COVID-19 restrictions will help us identify policy, programmes or resources with the potential to improve national public health strategies and preparedness for future emergency responses to achieve the best possible outcomes for caregivers. --- Unpaid caregiving to older care recipients in NZ pre-COVID-19: The scale of the issue Estimates suggest that 480,000 people provide regular care for someone with an illness or disability [16]. This figure underrepresents spouses, Māori and Pacific caregivers [17]. Caregivers in NZ are most likely to be between 50-54 years, and provide on average 30 hours or more per week of care [18] for 8 years and 10 months [19]. However, significant numbers of younger people, older people, and adult children provide care to older people [20], for example, 34% of caregivers who provide care for household members with illness/disabilities are aged 55+ years [21]. Care may be provided to an older person by a number of caregivers [22] and 65% of caregivers are simultaneously in paid employment [16]. Caregivers' ethnicity reflects the population in general, with Māori and European New Zealanders most likely to report providing care. European New Zealander caregivers are more likely to report providing support to someone living in a separate household, than caregivers of other ethnicities who are more likely to report co-residence [17]. Caregiving for older people living with dementia is a major public health issue for societies worldwide. It is estimated that there are presently 70,000 people living with dementia in NZ, and the number is predicted to increase to 170,212 by 2050 [23]. In 2020, almost 87% of those with dementia in New Zealand were of European ethnicity, with Maori and Pacific people accounting for 6.2% and 2.8% of the population of people living with dementia respectively. Dementia is the largest single contributor to disability and need for care among older adults [24]. Globally, the vast majority of support and care for people living with dementia is provided through unpaid kin/non-kin networks [25]. In 2016, there were approximately 40,000 unpaid caregivers providing 45 million hours of care annually to people living with dementia in NZ, with an estimated cost of NZ$68.6 million [23]. Under normal circumstances, the provision of care and support to people living with dementia in the community can result in significant physical, emotional and economic strain for caregivers [26][27][28][29][30][31][32]. While we expect some features of caregiving to be similar regardless of the functional or cognitive characteristics of the person being cared for during the COVID-19 pandemic, we also anticipate that caregivers to people living with dementia faced some unique challenges . --- Multilevel influences on caregiving pre COVID-19: The breadth of the issue Pre-COVID-19 pandemic research identified several layers of influence on the caregiving experience. Within a human ecological systems framework, outcomes for caregivers and care recipients are influenced by social structural and cultural norms, community, institutional/organisational factors, interpersonal processes and intrapersonal factors and the interaction between these factors . Social structural and cultural influences on caregiving. The NZ healthcare system depends heavily on caregivers to provide support for older people [34]. Although government policies draw attention to the need to recognise the important role of family caregivers [35,36] there remains little acknowledgment of their critical contributions to society [37][38][39]. National and local policies are responsible for eligibility and allocation of resources to caregivers/recipients, but bureaucratic obstacles [40] and difficulties with navigating health and social care systems present barriers to accessing services [41][42][43]. Some policies suggest that apps, online resources and social media may facilitate caregivers' connections with service and information, especially in isolated communities [35,44], while others acknowledge that caregivers may need navigational help to receive the support and information they need [36]. The current Carers' Strategy Action Plan 2019-2023, Mahi Aroha, states that caregivers should be supported to continue in employment and to fully participate in a social life while providing support [36]. Despite these policy commitments, there is evidence of a strong direct relationship between caregivers' increasing sense of burden and discontinuation of their caring role [45]. In addition to public policy, there are cultural influences on caregiving. The term 'caregiver' may not resonate with everyone and there are cultural differences in usage [46]. Obligations to provide care that are based on normative expectations of family solidarity may not be referred to as 'caregiving', and is an important reason why caregivers do not seek out services [47]. For Pacific peoples, older people are revered and caring for them is a prioritised service to one's family [48,49]. Samoan people, for example, believe that caring for elders is an obligation and in return children will gain blessings . For Māori, family care of older people is founded on commitment to reciprocal relationships and obligations to help [50] where older people are "carriers of culture, anchors for families, models for lifestyle, bridges to the future, guardians of heritage, and role models for younger generations" [51]. Family care is perceived as "normal" [52][53][54] and critical to the wellbeing of older people in the context of a significant ageing population and health inequities for Māori [55][56][57][58][59]. In caring for older people with dementia, family are crucial in promoting a healthy spirit or soul [53]. The collective obligations of the family are informed by concepts such as love , showing respect, generosity and care for others , genealogy and relationships building through shared experiences and working together which provides a sense of belonging [53]. Māori family caregiving sits at the heart of the wellbeing approach to care work integrating cultural identity, sustainability of the Māori world view , social connections, knowledge and skills, human resource potential, and income [36]. Very little is known about the support needs of Māori family-based care networks, or Pacific care networks although caregivers have multiple demands on their time [60][61][62]. Pacific [63,64] and Māori caregivers [53] are among those most in need of support, but are less likely to be aware of available services [47] and more likely to have lower levels of health literacy than European New Zealanders [65][66][67]. In this context, health literacy refers to the 'degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions' [63]. The additional challenge of English as a second language creates barriers in accessing health care services [63]. Both Māori and Pacific peoples have reported discrimination in health care services [68]. It has been suggested that health care providers need to work on their cultural competency, communicating information that resonates with the values and contexts of Māori and Pacific people, and developing appropriate outreach mechanisms to identify and connect with caregivers from different cultural groups [69][70][71]. Community/Neighbourhood influences on caregiving. In NZ, caregivers face significant challenges according to their geographic location or area deprivation [72]. The remoteness of communities affects access to health, social care and other essential or community services [44,73]. People living in remote rural areas are less likely to have a landline or cell phone coverage [44,74]. Furthermore, area disadvantage may impact negatively on health outcomes for older caregivers [75]. Neighbourhoods have the potential to positively shape health, quality of life, and well-being for caregivers through the provision of local services, a sense of attachment to place [76,77] and social interactions in 'third spaces' [78,79]. In places with fewer opportunities for community participation and lower levels of social capital, caregivers of people living with dementia are more likely to report higher levels of isolation and find it harder to manage the demands of care [80]. In rural communities, there may be increased emphasis on family support, because of reduced options for alternative sources of support [81]. However, rural communities may be subject to ongoing population change and instability, and sources of formal or informal support may be stretched thinly [82][83][84]. Additionally, there may be an increased risk of abusive caregiver-recipient relationships, as there can be limited contact with people who could identify abuse or offer support in rural communities [81]. Organisational influences on caregiving. Unpaid caregivers perform an essential function as 'care-coordinators' linking older care-recipients to health care services, including primary health care and general practice. Caregivers attempt to meet gaps in formal health and social services for older adults [8,[85][86][87][88][89][90][91], advocating for care recipients, [43,85,[92][93][94], facilitating access to, and explaining health information [86,95]. High-quality care at home relies upon strong relationships between health professionals and caregivers, good communication [62,96,97], and collaborative working [35,98]. In NZ, services and support for caregivers is provided through primary care, District Health Board funded community services and non-governmental organisations [43,99] and the Supported Living Payment. Despite some recent effective cross-sectoral coordination [43,61,62,[88][89][90] the uptake of caregiver support is low, indicating a lack of flexibility [43,100], inadequate provision [43], lack of knowledge about services [101], and a disconnection between what is offered and what is needed [102]. Unmet needs for formal services places increased demands on caregivers [103] and organisations may provide services that are neither relevant to caregivers needs and consistent with their wishes [40], nor socially, culturally or linguistically appropriate and accessible. For working caregivers, the organisational characteristics of employers are also important. Juggling work and caregiving roles can impact negatively on health and well-being, especially where employers do not have caregiver support strategies or have inflexible working policies [104,105]. The Employment Relations Flexible Working Arrangement Act 2007/2008 allows employees to request flexible working arrangements. However, fewer than one-third of workers are aware of this and many use annual or sick leave to provide care [106]. Furthermore, many caregivers reduce working hours or exit the workforce in order to provide care to an older person [104,107], often negatively influencing their financial resources [108]. Family, social networks, interpersonal relationships influence on caregiving. Unpaid care-networks of older people may comprise partners, family networks, or mixed networks [109][110][111][112][113] and the quality and extent of support are critical to caregivers' experiences. Particular caregiver-recipient relationships may produce different outcomes, for example, spousal caregivers have worse mental health outcomes than adult-child caregivers [114]. Furthermore, not all caregiver-recipient relationships are positive: conflict, tension and negative interactions are salient [115,116]. Kin-networks may be disrupted by divorce and remarriage which may alter intergenerational bonds and responsibilities. Negative interactions within stepfamilies or discordant coordination of care within families can lead to greater levels of depression and caregiver burden [115,117]. The risk of abusive relationships increases when individuals, families are isolated, or when caregivers do not receive appropriate support [17]. Individual characteristics and resources influence on caregiving. A large body of global research emphasises negative impacts of caregiving on physical, psychosocial, emotional, social and financial circumstances, otherwise known as 'caregiver burden' [118]. In terms of health equity, the risks for poor mental and physical health associated with caregiving have been highlighted [119][120][121], especially for caregivers of people living with dementia [26][27][28][29][30][31]. In NZ, caregivers are more likely to experience poor health [108] depression and anxiety than noncaregivers [122]. Research suggests that female caregivers and Māori caregivers have the poorest mental health [19] suggesting that these are the downstream corollaries of social, economic, cultural and political inequities. Elsewhere, research has demonstrated that caregiving elicits a high economic burden [20]. However, little is known about the costs incurred by family caregivers in NZ [22]. Caregivers may experience out-of-pocket expenditure on services , goods , home adaptations to improve accessibility, increased heating, laundry and transportation fees [123], but may also incur a loss of income associated with changes to employment [20]. Caregivers in NZ have lower economic living standards compared to non-caregivers [108]. An inadequate income increases the risk of poor health and depressive symptoms for caregivers [124], and can restrict access to private care services [40]. As identified above, much of the academic literature on caregiving to older people focuses on negative outcomes, implying that it is financially physically and psychologically harmful [119]. This has been referred to as the 'penalties of caring' [46]. However, it is also important to recognise positive aspects of caregiving that are often ignored or not assessed. Being able to provide care for a loved one is often highly valued [79,125]. Emphasising positive aspects of the role can improve the sense of self-efficacy, feelings of accomplishment, the quality of the caregiver/care-recipient relationship and reinforce caregiver wellbeing [126]. --- Unpaid caregiving to older care recipients during COVID-19: Our knowledge of the issue Knowledge of the impact of COVID-19 on caregivers is emerging. For example, a survey by Carers NZ/NZ Carers Alliance provided an insight into the experiences of 676 caregivers during the COVID-19 pandemic [127]. The survey highlighted several issues including reduced access to services and essential supplies, concerns about paid care staff coming into contact with the care recipient [128], increased exhaustion and stress, and financial pressures. Although the survey provides an indication of some challenges, we are unable to distinguish between the concerns of caregivers providing support to older people or people living with dementia from others, or whether caregivers from different cultures/ethnicities, social or geographic locations experienced particular inequities in health and care provision. From our understanding of the factors that impacted on caregivers before the global pandemic, we can postulate that some of these will have been amplified during COVID-19 as the related measures are likely to have been an additional contextual stressor [129]. At the policy level, while general announcements and updates were praised for keeping the population of NZ informed about key developments during the pandemic [127] to date, no research has assessed whether the information and resources addressed caregivers' needs, or whether there are unresolved issues that still need to be tackled in order for us to be prepared for future scenarios. For example, was guidance culturally safe and sensitive for Māori and Pacific caregivers [130]? Were there suitable support systems for caregivers who lived at a distance from care recipients? And were generic resources suitable for caregivers supporting people living with dementia? At the organisational level we need to understand whether clinical home care service guidelines need updating in light of caregivers experiences during the pandemic. We also need to understand how employers supported working caregivers, and how this impacted on the caregiving experience. At the community level, framing unpaid caregiving through families in terms of reciprocity, obligation, solidarity and love [131] is in danger of glossing over issues of social justice and inequity at the community level. Some communities could be described as impoverished care environments and may be least equipped to meet a such a social care agenda [132]. We need to identify inequities in health and social care support, and access to others services for caregivers in disadvantaged communities or living at a distance from 'resource centres' [133]. We also need to know more about exclusion from access to information due to a digital divide in access to broadband internet services [134] and whether caregivers living in communities that experienced unequal access before lockdown have been pushed further to the margins. At the interpersonal level, many caregivers rely on the stability and connection of their family and kinship systems. We do not know the extent to which family and caregiving networks were hampered or enabled by social distancing requirements during COVID-19. The caregiver-care recipient relationship may have also been strained due to increases in caregiving tasks, hyper-vigilance, and less respite. At the individual level, in addition to the greater impact on personal resources, COVID-19 probably altered the daily life of employed caregivers [128,135,136]. In addition, some caregivers may have faced additional child-care pressures exacerbated by school and nursery closures. Research in the United Kingdom suggests that caregivers sought to reduce their own risk of infection, to protect older care recipients [128]. Consequently, caregivers employed in 'essential services' may have felt conflicted about undertaking work duties that could potentially put an older care-recipient at risk of infection. We need to understand the situation of caregivers , in terms of burden, physical and mental wellbeing, burnout [130], sleeplessness [137], social isolation and loneliness [138]. --- A critical human ecological framework to examine caregiving during COVID-19 Globally, unpaid caregivers are a crucial human resource that improve health-care capacity especially in areas with inequitable/sub-optimal access to health and social care. A critical human ecological approach [139] provides a meta-framework for challenging health inequities and will be used to question taken-for-granted assumptions about caregivers during the COVID-19 pandemic. These assumptions included the continuing capacity of caregivers to provide care, their psychological-preparedness to provide support, their functional capacity to cope with demanding and physical caregiving tasks without respite [130], and their financial capacity to bear the brunt of additional caregiving costs. Additionally, there were implicit assumptions that caregiver-recipient relationships would be mainly co-resident dyads with little attention paid to the implication of social restrictions for non-co-resident caregivers, or caregiving that was distributed throughout families. This research will examine the intersectionality of structural inequities, focusing on subgroups of caregivers who may face particular challenges, or may be excluded from existing policy [140], that is, those living in remote, rural disadvantaged areas [141], and Māori and Pacific caregivers. The critical human ecological framework has been selected to situate this research because this approach recognises that caregivers are embedded in different social or cultural groups, and that intersecting settings or levels of the model influence health equity and wellbeing. The health equity and wellbeing of caregivers will be conceptualised as an emergent product of a system, in which individual, community, environment and macro-structures are inextricably connected [142]. While this research will highlight health inequities that are the result of the intersectionality of structural inequities, the COVID-19 pandemic also provides a unique opportunity to maximise learning from any positive ways in which caregiving was disrupted. For example, opportunities to work at home [128], or to receive remote medical consultations , may have provided benefits that could or should be extended into life beyond the pandemic to improve quality of life. Taking a citizen-centred approach, the goal of this research is to provide the opportunity for caregivers in NZ to have a voice in shaping recommendations for future health and social policy, and services [143]. It will contribute to the development of solutions that are culturally responsive and relevant to NZ. Our international collaborations will provide the opportunity to identify experiences that were common to caregivers during the pandemic and point to vulnerabilities and areas that may require national and international reform to reduce the risk of future public health crises impacting on caregivers. --- Objectives The objectives of this study are: • To undertake interviews with caregivers, and select caregivers' letters from an extant archive, in order to understand the challenges and rewards associated with caregiving to older care recipients during the COVID-19 pandemic restrictions. • To undertake interviews with organisations providing services to caregivers and older people, in order to map and collate resources developed during the pandemic. • To hold workshops and a co-design challenge event to co-produce policy recommendations, identify useful caregiver resources and practices, prioritise unmet needs . • To use project results in knowledge translation, in order to improve caregivers access to resources, and raise the profile and recognition of caregivers contribution to society. --- Research questions The research will address the following questions: 1. What were the experiences of Māori, Pacific and rural-dwelling caregivers in NZ during the COVID-19 pandemic? 2. What were the similarities and differences between the experiences of caregivers for people living with dementia compared to caregivers providing care for older people with other health and disability needs? 3. How did the interrelated systems of the human ecological model impact on caregiving experiences during the COVID-19 pandemic? 4. What can we learn from the experiences of caregivers and organisations supporting them, to prepare for other similar situations, or to transfer to new ways of working in everyday life? --- Methods This study uses take a participatory action research approach [144,145]. Phases 1-2 will underpin co-design activities in Phase 3 . The co-production of knowledge is often referred to as integrated knowledge translation which describes an ongoing relationship between researchers, community groups and policy-makers for the purpose of engaging in a mutually beneficial research to support decision-making [146,147]. Using participatory action research, integrated knowledge translation [148] will be achieved through a reflective cycle, whereby community partners collect and analyse data, and along with caregivers, identify what actions should follow. Four main elements underpin our co-created research: collaboration and equitable involvement in research; solidarity and capacity-building; empowerment and action for systems change; and sustainability [144]. Accordingly, all partners have actively contributed to the proposal, [144] in order to deliver customised research to improve local practice [149]. --- Phase 1: Experiences of caregivers Sample and setting. Two samples will be used in Phase 1 of the study, extant data and new primary data. --- Extant data for caregivers extracted from a study entitled Social connectedness among older people during Covid-19 (Auckland Medical Research Foundation; Principal Investigator Professor Merryn Gott ). This study requested letters from people age � 70 years living in NZ describing their experiences of COVID-19. Data collected between May 2020 and May 2021 comprises >650 responses. We will select letters sent by older caregivers from the main dataset by searching files for key words . 2. A new cross-sectional purposive critical case sample [150] of caregivers providing support to 15 older people living with dementia, and 15 without dementia . Established and trusted relationships are critical to conducting community research [151]. Participants will be volunteers identified through our collaborating community group networks who live and work within the communities. Study design. In a cross-sectional qualitative study, caregivers who provide care or support to an older person, within the three groups/settings will be invited to take part in face-toface guided interviews in their own homes, or in a setting of their choice. Individual, joint, or family-based interviews will be offered to participants. Consequently, the number of caregivers interviewed is likely to be greater than 30. Face-to-face interviews are preferred by Māori caregivers [123] and caregivers with mobility, hearing or vision difficulties who may encounter difficulties with written responses or telephone interviews [152,153]. However, if the Alert Levels associated with the COVID-19 pandemic are in place and we are unable to interview face-to-face, we will adopt a contingency plan and conduct interviews by Zoom/Skype/ telephone [154]. A short questionnaire will be used to establish the demographic characteristics of the caregiver . An interview guide will be aligned to the 'levels' of the human ecological model and will focus on the individual, interpersonal relationships, organisational issues, community and public policy and culture . The first area of enquiry will focus on the individual and is structured to establish changes in caregiving during COVID-19 restrictions and positive and negative outcomes on personal resources and wellbeing. This section will also explore whether there were challenges balancing caregiving and additional roles during COVID-19 restrictions. The second section will explore family, social networks, interpersonal relationship in relation to caregiving. The third section, the organisational area of enquiry, will establish whether clinical home care service guidelines need updating in light of experiences during the pandemic. The topic guide will cover issues relating to encounters with home care providers during COVID-19, use of telecare and telehealth, alongside issues concerning the availability of resources , and the impact on caregivers. The fourth section, focusing on the community/neighbourhood area of enquiry, will identify inequities in access to services for caregivers in disadvantaged communities and for those living at a distance from resource centres. The fifth section will address the social structural and cultural area of enquiry, and will explore whether information and resources developed during the pandemic addressed caregivers' needs, or whether there are unresolved issues that still need to be tackled in order to be fully prepare for future scenarios. A modified interview guide will be used for group interviews with two or more caregivers: some questions will be directed at the main caregiver, while others will be asked of each participating caregiver . Community Researchers working with Māori and Pacific caregivers will interview participants in Te Reo Māori , Samoan, Tongan, Niuean or English according to the caregivers' preferences. Face-to-face interviews will be informed by culturally aligned research ethics and processes. All participants will be offered NZ$50 voucher for their involvement in the research [155][156][157]. Analysis. A thematic analysis of secondary and primary cross-sectional qualitative data will be undertaken. Transcripts will be anonymised [158], imported and analysed using QSR NVivo Version 12. Drawing on social phenomenology [159] analysis will utilise both inductive and deductive thematic analysis to interpret the raw data within a framework analysis [160]. Familiarisation, conceptual and cultural understanding of the interviews will be clarified during team meetings. A first version of the coding index will comprise top level headings for themes heavily rooted in a priori issues . Two interviews from each group will be independently coded by the researchers during which categories will be identified and refined. The resulting index will be systematically applied to the text. Data will be charted into a framework to provide decontextualised descriptive accounts in relation to the different levels of the model and experiences during COVID-19 for each care-recipient . Schematic diagrams will be developed and used alongside the charted material to capture commonalities of experiences across caregivers [161,162] and at each level of the model . Chronological explanatory summaries capturing the complexity of experiences will be created for each participant describing the interrelationship between levels of the model [163]. A Māori Expert Advisory Group and the collaborating Pacific Research Group will help guide interpretation of Māori and Pacific data analysis. Researchers will meet regularly to discuss different ways of interpreting the research phenomenon, differences between groups, and the persuasiveness of the analysis [164]. --- Phase 2: Organisational support and resources for caregivers Sample and setting. In a cross-sectional qualitative study, a purposive sample of 30 national and local organisations across NZ who provided support to caregivers during COVID-19 will be selected through collaborating community organisations. Study design. CEOs/Directors of the service provider organisations will be contacted by phone/email to describe the purpose of the study. An appointment for a 30-45 minute telephone/Zoom interview will be made with the CEO/Directors or with a nominated member of the organisation. Guided interviews will follow a similar format to caregivers' interviews. The organisational representative will be asked for their perception of caregivers' successes and challenges during COVID-19. They will be asked to describe the organisational response to caregiver needs and asked to describe any resources/services that they developed specifically to address these . Analysis. Telephone/Zoom interviews will not be recorded or transcribed verbatim. As these interviews do not require a particular closeness between researchers and the interviewees, we will use a reflexive, iterative process of data management comprising concurrent notetaking; reflective journaling immediately post-interview; summarising the description of resources, and undertaking preliminary content analysis identifying emerging themes [165]. The interviewee will be sent a description of resources deployed/developed by the organisation and the major themes elicited in relation to the perception of caregivers met needs. The participant will be asked to verify and/or amend the summaries to ensure stakeholder engagement and 'member checking' [166,167]. The themes will be added to the framework analysis . The descriptions of resources will summarised into 'plain' language. For informational resources hard copies or URLs will be obtained. --- Phase 3: Co-produced resources, recommendations and priorities for caregivers Sample and setting. Caregivers who highlight an interest during Phase 1 will be eligible to participate in any of the co-creation workshops. We will organise six co-creation workshops to assess the adequacy of collated caregiving resources and prioritisation of unresolved challenges. We anticipate a maximum of five participants in each of these workshops. We will convene one creative co-design challenge event [168]. Caregivers from Phase 1 that express an interest in telling their stories on film will be invited to take part in digital storytelling. Study design. We will convene six workshops for ideation concerning appropriate recommendations and resource materials/ models to support family caregivers. Each workshop will last about 2-3 hours. They will be conducted by researchers skilled in hosting co-production events, and will use cultural ways of working. The first event will cover the following issues: • A summary of the key challenges faced by caregivers in each setting identified in Phase 1 • A summary of the resources deployed by organisations to meet caregivers' needs identified in Phase 2 • Discussion around whether resources met caregivers' key challenges during COVID-19 • Identifying good practice for future health disasters and emergency situations • Identification of good practice that could be applied to everyday life to support caregivers At the second event, the participants will discuss insights, ideas for new practices, services, policy recommendations: with particular attention given to identified unmet needs for information, practical health and social care support, health literacy, and psychosocial help. Ideas generated for new resources would be prioritised by each group to ensure successful application of study findings. In order to address any unresolved prioritised issues, a creative co-design challenge event would bring together stakeholders to address the challenges [168]. During the creative co-design challenge event, small teams would co-produce a brief and implementation plan to move each challenge forward beyond the project funding period. Results will inform the design of practice, policy and future collaborative studies to address areas of high priority as indicated by the caregivers. Three short films would be co-created to communicate caregiver 'stories'. An experienced researcher and a filmmaker will work with three individuals or groups to construct and share caregivers' own authentic narratives. The caregivers' interview transcripts will be used as an aide-me ´moire to create 'storyboards' which will serve as a visual layout for story construction. Each short film will comprise 5-6 minutes of visual narrative creating compelling accounts of caregiving experiences [169,170]. --- Results Data collection commenced in June 2021 and will be completed by September 2021. Analysis of data will feed into Phase 3 to develop caregiver resources, digital stories, recommendations for organisational good practice, policy and coordination. An integrated knowledge transfer strategy [146][147][148] will maximise the impact of outputs from the research within and beyond the grant lifecycle. Co-production and working with community-based partners and caregivers will result in realistic real-world application and will facilitate a pathway to impact through implementation of recommendations in primary care and maximising caregiver access to support resources. --- Discussion The need for this research was identified by our community partner groups. Subsequently, community groups and academics have risen to the challenge by jointly and collaboratively developing a proposal to identify and address the needs of specific sub-groups of caregivers who are likely to have been particularly affected by sub-optimal and inequitable access to advice, health and social care support and resources-that is Māori, Pacific and rural-dwelling caregivers. From the outset, the team has taken a participatory action research approach to project design which will continue throughout implementation to ensure translation of social research into public health benefit for family caregivers to older people . We anticipate that the research will have social, economic and cultural benefits. The research will improve caregivers' access to support resources, caregiving safety, effectiveness and cultural appropriateness during future emergency health situations. We will also identify good practice and resources developed during the pandemic that could be rolled out to positively impact on caregivers' everyday life. Furthermore, the research is anticipated to improve the responsiveness of health and social services to meet caregivers' needs, especially in populations that are vulnerable to exclusion and health inequity. At the end of the study, resources will provide practical solutions for challenges associated with caregiving during and beyond the pandemic, especially for Māori, Pacific and caregivers living in remote, rural or disadvantaged areas. As shortfalls in support impact on caregiver burden, physical and cognitive health, quality of life, and other psychosocial outcomes , we anticipate providing lasting societal benefits, potentially delaying institutionalisation of older care recipients, and reducing health and social care costs. The social, economic and cultural benefits will be achieved through the collation and distribution of best practice and support resources, recommendations for policy , and identifying unresolved challenges to be addressed beyond the funded duration of the project. Examining caregivers' experiences in more than one location with international partners will help to identify good practice, and perhaps clarify the drivers of suboptimal support, while deepening our knowledge about needs and expectations of caregivers. In turn, this could improve the quality of care, support and services, by broadening and strengthening evidence for change beyond the confines of a single nation. --- S3 Appendix. Semi-structured interview guide for groups . S4 Appendix. Semi-structured interview guide for service providers. --- The datasets generated and/or analysed during the study will not be made publicly available as restrictions apply to the availability of these data (intention of data identify a suite of resources for caregivers to use in future events requiring self-isolation, and in everyday life; and generate ideas to address unresolved issues. --- Ethics Ethical approval was obtained from the Auckland Health Research Ethics Committee on the 31 May 2021. --- Supporting information

Knowledge of the challenges unpaid caregivers faced providing care to older people during the COVID-19 pandemic is limited. Challenges may be especially pronounced for those experiencing inequitable access to health and social care. This participatory action research study, located in New Zealand, has four main objectives, (i) to understand the challenges and rewards associated with caregiving to older care recipients during the COVID-19 pandemic restrictions; (ii) to map and collate resources developed (or mobilised) by organisations during the pandemic; (iii) to co-produce policy recommendations, identify useful caregiver resources and practices, prioritise unmet needs (challenges); and, (iv) to use project results in knowledge translation, in order to improve caregivers access to resources, and raise the profile and recognition of caregivers contribution to society.Māori, Pacific and rural-dwelling caregivers to 30 older care-recipients, and 30 representatives from organisations supporting caregivers in New Zealand will be interviewed. Combining data from the interviews and caregivers letters (from an archive of older people's pandemic experiences), framework analysis will be used to examine the interrelated systems of the human ecological model and the impact on caregiving experiences during the pandemic. Resources that service providers had created or used for caregivers and older people will be collated and categorised. Through co-production with caregivers and community partners we will produce three short films describing caregivers' pandemic experiences;

Background Novel coronavirus pneumonia is an acute respiratory infection caused by the severe acute respiratory syndrome coronavirus , first identified in Wuhan, China, in December 2019 [1]. COVID-19 has rapidly spread worldwide since its emergence, presenting a global pandemic and posing a serious threat to human life and health. As of November 7,2022, some 629 million cases had been reported globally, with more than 6.5 million deaths [2]. Therefore, in order to prevent people from contracting COVID-19 and to ensure their health and lives, China has taken measures such as restricting transportation, postponing the resumption of work and school, and suspending or postponing most sports competitions to minimize the flow and gathering of people. Students attended classes at home via the Internet, workers worked at home or temporarily stopped working, and people's habits and quality of life were greatly affected [3][4][5]. For a profession such as football refereeing, which works mainly on outdoor football pitches, there are even greater difficulties and challenges. Football referees are an integral part of the game and are needed at all levels and age groups. According to the rules of the game published by FIFA, there must be an on-site referee , two assistant referees , and a fourth official in an official football match. In 2014, there were about 20,000 registered football referees in China [6]. The number of international referees announced by the Chinese Football Association in 2023 is only 32 [7]. Although China has a clear hierarchy of referees and a perfect training management system, due to the late start of the Chinese professional football league and the overall scale of the tournament being on the rise, the Chinese Football Association has only implemented a professional referee system for some referees in the Chinese Super League, and most referees are still under the management of the amateur referee system, while, as the Chinese professional football league consists of three tiers of leagues, the high level of football matches are few and the demand for referees is limited, which has led to problems such as a small number of referees, few matches officiated and a lack of competence in China [8]. The salaries of football referees are strongly linked to the number of matches they participate in; however, the new crown pneumonia quarantine policy has led to the postponement or suspension of all sporting events, which has largely reduced their income and increased their financial and survival concerns. As the contagiousness and mortality rate of COVID-19 have declined, some sporting competitions have gradually resumed in China, but all those involved must be isolated for the duration of the competition, leaving football referees not only under pressure from the specificity of their profession but also unable to interact face-to-face and socialize to relieve their fatigue [9]. The accumulation of occupational stress can easily lead to burnout, which can impair the quality of life and physical and mental health of football referees [10][11][12][13]. In addition, there are significant challenges in how to continue to develop football in China after the relaxation of the embargo and social distance guidelines, to conduct football matches, and to promote the football referee workforce [14]. The World Health Organization defines the quality of life as the overall satisfaction of individuals in different cultures and value systems with their living conditions concerning their goals, expectations, standards, and concerns, as well as their general sense of personal health [15]. It is a comprehensive measure of well-adjusted physical, psychological, social, and environmental well-being. A large number of studies have shown that during the COVID-19 pandemic, many countries have adopted lockdown and quarantine measures, and people's lifestyles have changed greatly [16][17][18]. COVID-19 lockdown has reduced people's physical activity and increased sedentary time [19], which may lead to a decrease in the physical fitness and motor skills of referees. Long-term social isolation can lead to feelings of loneliness [20] and even symptoms of insomnia, anxiety, and depression [21]. In addition, isolation makes people unable to communicate with relatives or friends face to face, family support and social support are reduced, and people have nowhere to vent their negative emotions, such as fear and pressure caused by the COVID-19, and cannot get comfort and support from others, which is prone to mental health problems [22]. Therefore, the COVID-19 blockade can have a negative impact on people's quality of life. However, studies in the USA, Poland, and Saudi Arabia found no significant direct effects of COVID-19 on the quality of life of students or adults [23][24][25]. For soccer referees, they have to travel 10 to 12km to make more than 100 decisions in every soccer match [26]. They must be in good physical and mental condition to make the right decision. On the one hand, the lockdown of COVID-19 has made football referees less physically active and lack organized training and competition, which may lead to a decline in physical fitness and professional skills [27,28]. On the other hand, because the salary of football referees is related to the number of matches they play, the temporary suspension of work causes them to suffer financial pressure and uncertainty in their career development. This has a great impact on their quality of life [14,29]. Therefore, hypothesis 1 is formulated: The COVID-19 lockdown harms the quality of life of Chinese football referees. Stressors refer to environmental demands or threats that individuals find difficult to cope with [30]. According to the theoretical model of stressors proposed by Robbins, potential factors leading to stress include the environment, organization, and individual. When people feel pressure, they will have some physical, psychological, and behavioral symptoms [31]. The COVID-19 is highly infectious, spreads quickly, and the virus antigen is easily mutated. After infection, there will be symptoms such as breathing difficulties, cough, palpitation, muscle soreness, and even life-threatening [32]. COVID-19 lockdown, as a social and environmental stressor, has an important impact on people's physical and mental health and quality of life [33,34]. Occupational stress refers to the physical and psychological stress caused by the imbalance between objective requirements and self-adaptive ability in the process of work, which is a non-specific abnormal psychological response [35]. The lockdown of COVID-19 has reduced people's physical activity, physical fitness, and sleep quality [36], and they are worried about not being able to recover their previous health status and skill level [37,38]. For football referees, physical fitness and professional skills are the foundations of their career development. After being quarantined at home for a long time, they will worry about the decline of physical strength and the occupational pressure caused by poor professional skills in the early days of sports competitions [39]. A study of French athletes showed higher anxiety scores when they returned to competition after COVID-19 [40]. Occupational stress is an important factor affecting the quality of life [41]. Long-term, high-intensity occupational stress will cause job burnout, reduce job satisfaction, produce physical and mental health problems [42], and decrease the quality of life [43]. Therefore, hypothesis 2 is formulated: Occupational stress mediates the relationship between COVID-19 lockdown and quality of life. Burnout is a long-term state of emotional, physical, and mental exhaustion [44,45], which Maslach et al. believe includes emotional exhaustion, depersonalization, and low personal accomplishment [46]. Job burnout refers to the state of physical and mental fatigue and exhaustion produced by individuals under heavy work pressure, which is defined as a chronic work stress syndrome by the World Health Organization [46]. Previous studies have shown that job burnout is related to sociodemographic and job-related factors, including age, marital status, work experience [47,48], wage level [49,50], work stress, social support, etc. [51][52][53]. According to the job demand-resource model, job demand refers to employees' demands on individuals' physical, psychological, and social abilities in their work. Job resources are factors related to employees' work planning, professional cognition, and organizational development that can promote the realization of employees' work goals. When work demands and work resources cannot match, blindly consuming work resources will lead to job burnout among employees, which will lead to physical and mental health problems, decreased work efficiency, and low job satisfaction [54]. The COVID-19 lockdown has led to the cancellation or postponement of almost all sports matches, and the salary of Chinese football referees is closely related to the number of matches they participate in. Therefore, the COVID-19 lockdown has put football referees under greater economic pressure. In addition, due to the lockdown, football referees have reduced their physical activities, lack normal training and referee performance, and their professional ability is at risk of declining. Therefore, in the early stages of recovery, the lack of professional ability and self-efficacy, as well as the great pressure of refereeing, will lead to job burnout [55,56], which will affect the physical and mental health and quality of life of the employees [57][58][59]. Therefore, hypothesis 4 is formulated: Job burnout mediates the relationship between COVID-19 lockdown and quality of life. A large number of studies have shown that COVID-19 lockdown and isolation measures increase people's fear, stress, anxiety, and depression [60,61], which have a great impact on their work and lives. For athletes, referees, and other groups who usually have a lot of exercises, the lockdown of COVID-19 makes them have to change their exercise habits and work status and even adjust their expected career plan [62]. The prolonged lockdown and isolation have reduced their physical fitness and professional skill proficiency, which has increased their occupational pressure to some extent. Job burnout is an extreme reaction when individuals cannot cope with work pressure smoothly, and it is a state of exhaustion of emotions, attitudes, and behaviors produced by individuals under long-term pressure [63]. Studies have shown that occupational stress has a direct positive impact on job burnout, and employees who experience job burnout will suffer from decreased work efficiency, physical and mental health problems [64], decreased life satisfaction, and thus reduced quality of life [43,59]. Therefore, hypothesis 4 is formulated: Occupational stress and job burnout play a chain-mediated role between COVID-19 lockdown and quality of life. In short, the current studies on the impact of the COVID-19 lockdown on quality of life mostly focus on medical staff and students, and most of the studies in the sports industry also focus on athletes, with little research on football referees. To our knowledge, there are no more than 30 studies on the impact of the COVID-19 epidemic on football referees, and most of them focus on physical function, professional skills, and mental health, while there is only one piece of literature on Chinese football referees [39]. Therefore, based on the stressor theory model and the job demand-resource model, this paper explores the impact of the COVID-19 lockdown on the quality of life of Chinese football referees as well as the influencing mechanisms of occupational stress and job burnout. Based on the literature review above, we propose a hypothesis and a hypothesis model . --- Methods This is a cross-sectional study using convenience sampling and snowball methods, conducted through an online questionnaire platform from Au-gust to September 2022. Before completing the questionnaire, participants were in-formed that the survey was anonymous and confidential, and their informed consent was sought. A total of 350 questionnaires were sent out and 338 were recovered, for a recovery rate of 96.57%. The inclusion criteria for the sample were: age ranged from 19 to 45years old and came from 29 provinces in China; referees registered with the CFA at level 3 or above; and taking no less than 10min to complete the questionnaire. During data pre-processing, we removed missing data and invalid samples that took less than 10min to answer the questions and those that did not meet the inclusion criteria, and the final remaining 307 samples were screened. Among them, 254 were male and 53 were female. 108 had been referees for less than three years, 73 for three to five years, 42 for six to eight years, and 84 for more than eight years. There were 40 referees with national referees, 103 with first-class referees, 95 with second-class referees, and 69 with third-class referees. Referees have a high level of skill and have many years of experience refereeing matches in the Chinese Football League. This is a nationally representative sample of data. The survey was approved by the Ethics Committee of the School of Basic Medicine of Shandong University . --- Research instruments In addition to demographic data such as gender, age, education, and referee performance, the study added four dimensions of quality of life to the hypothesis model: physical domain, psychological domain, social relations domain, and environmental domain. --- Impact of Events Scale-Revised The Chinese version of the Impact of Event Scale-Revised was used to measure the reactions of Chinese football referees after the COVID-19 lockdown. The scale was developed by Weiss and Marmar [65] and consists of 22 entries with respect to intrusion, avoidance, and hyperarousal. It is rated on a five-point scale from 0 to 4, with 0 being no impact and 4 being severe impact. The main statistical indicator is the total score, which ranges from 0 to 88. According to the instrument, the level of impact can be classified as follows: 0-8 is non-existent, 9-25 is mild, 26-43 is moderate, and > 44 is severe psychological impact [66]. The IES-R scale has been shown to have good reliability and validity in Chinese populations [67]. In this study, Cronbach's alpha was 0.946. --- Effort-Reward Imbalance Scale The Chinese version of the Effort-Reward Imbalance Scale was used to measure the job stress of Chinese football referees. ERI was developed by Siegrist, and the Chinese version of the questionnaire has good reliability and validity [68]. The questionnaire consists of 23 items, of which 6 measure effort, 11 measure reward, and 6 measure overcommitment. All dimensions were rated on a 5-point likert scale, with higher scores reflecting more effort, reward, and over-commitment. The raw score of the reward was obtained through reverse scoring. The total score for each dimension is divided by the number of items to obtain an average score. The ratio between effort and reward scores is an indicator of ERI. Football referees with a ratio > 1 are defined as highly stressed [69]. The Cronbach's coefficient of the scale in this study was 0.670. --- Maslach Burnout Inventory General Survey The Chinese version of the Maslach Burnout Inventory General Survey [70], which was used to measure the job burnout status of football referees, The scale consists of three sections: emotional exhaustion, cynicism, and reduced personal accomplishment. The emotional exhaustion component consists of 8 questions, the cynicism component consists of 6 questions, and the low sense of accomplishment component consists of 8 questions, for a total of 22 questions throughout the questionnaire. All dimensions are scored on a 5-point likert scale, with 0 being "never" and 6 being "very often". The higher the score, the higher the level of burnout. The scale has been verified to have good reliability and validity in the Chinese population and reports a three-factor structure and good internal consistency across the sub-scales in China [71]. In this study, Cronbach's alpha was 0.856. --- World Health Organization quality of life-BREF scale The Chinese version of the World Health Organization quality of life-BREF scale is used to measure the quality of life of Chinese football referees. The scale is a cross-cultural self-management scale consisting of 26 questions. Quality of life is assessed in four different areas: physical , psychological , social relationships , and environment . Responses varied according to a five-point likert interval scale. Each WHOQOL-BREF item has a score range of 1-5, while each WHOQOL-BREF dimension has a score range of 4-20. A lower score means a poorer quality of life [72]. In this study, Cronbach's alpha was 0.941. --- Statistical analysis We used SPSS 24.0 and Mplus 8.0 in this study for data analysis and structural equation model testing. The mean and standard deviation were used for all continuous variables, and quantity and percentage were used for categorical variables. First, SPSS was used for descriptive analysis, analysis of variance, and the Pearson correlation test. Then, the structural equation model test was performed using Mplus, using chi-square , the goodness of fit index , TLI, the adjusted goodness of fit index , SRMR, and the approximate root mean square error . Finally, Models 4 and 6 from the 3.3 version of PROCESS Macro were used to conduct mediating effects and chain mediating effects tests, respectively. Using the 5000 bias correction Bootstrap method, the mediating effect was significant if the 95% confidence interval did not contain 0. --- Results --- Common method deviation test We used the Harman single-factor test to check for common method bias [73]. The results showed that 18 factors all had characteristic roots greater than 1, and the cumulative variance extracted from the first factor was 22.76%, less than 40%. Therefore, there are no serious common methodological biases in this study and it can be continued. --- Descriptive statistics and correlation analysis Table 1 shows the detailed demographic characteristics of this study. Pearson correlation analysis was conducted for COVID-19 isolation, occupational stress, job burnout, quality of life, and four dimensions of quality of life , and the results are shown in Table 2. COVID-19 isolation was positively correlated with occupational stress and job burnout and negatively correlated with quality of life and its four dimensions. Occupational stress and job burnout were positively correlated with quality of life , and its four dimensions were also significantly negatively correlated. In addition, we also looked at the distribution of the four dimensions of quality of life . We used Mplus 8.0 to test the structural equation model composed of COVID-19 lockdown, occupational stress, job burnout, and quality of life. According to the hypothesis proposed above, the structural equation model was constructed with COVID-19 isolation as the independent variable, quality of life as the dependent variable, occupational stress and job burnout as the mediating variables, and gender and education level as the control variables. As shown in Table 3, the model fitting index was χ 2 /df = 4; CFI = 0.977; TLI = 0.931; RMSEA = 0.066; SRMR = 0.034. The model fits well. Therefore, hypothesis 1 is valid. First, we applied models 4 and 6 in PROCESS in SPSS [74] and resampled 5000 times using the deviationcorrected percentile Bootstrap method to calculate the 95% confidence interval for the mediation effect. The results are shown in Table 4. The effect values of three indirect effect paths were -0125, -0.096 and -0.043, respectively. Their 95% guiding confidence intervals do not contain 0 , so the three pathways are significant, that is, occupational stress has an intermediary role between COVID-19 lockdown and quality of life, hypothesis 2 is valid; Job burnout has a unique mediating role between COVID-19 lockdown and quality of life, and hypothesis 3 is valid; Occupational stress and job burnout have a chain mediating effect between COVID-19 lockdown and quality of life, and hypothesis 4 is valid . To further explore the specific aspects of the COVID-19 lockdown affecting the quality of life through occupational stress and job burnout, this study tested the mediating effect of the four dimensions of the quality of life respectively. The analysis results show that the direct effect of COVID-19 lockdown on the four dimensions is not significant, but in the physical field, there are three paths: COVID-19 lockdown → occupational stress → physical field, COVID-19 lockdown → job burnout → physio-logical field, The 95% -0.061], [-0.120, -0.030], and [-0.053, -0.013] respectively, all excluding 0. Therefore, the COVID-19 lockdown can affect the social relations of Chinese football referees through occupational stress and job burnout. To sum up, the four dimensions of quality of life all meet the chain mediation model . --- Discussion The main purpose of this study is to reveal the impact of the COVID-19 lockdown on the quality of life of Chinese football referees and the mediating role of occupational stress and job burnout. The results showed that the COVID-19 lockdown had no significant effect on the quality of life of Chinese football referees, but the COVID-19 lockdown could indirectly affect the quality of life of Chinese football referees through occupational stress and job burnout. In addition, the four dimensions of quality of life also meet the chain mediation model. It has been shown that COVID-19 does not have a significant direct effect on people's quality of life. This is consistent with the findings of several previous studies [23][24][25]. Most studies have found that COVID-19 lockdown can reduce people's physical activity, increase sedentary time [9,75], cause mental health problems such as stress, anxiety, and depression [76], and reduce the quality of life. Home isolation is also likely to cause family conflict [77], reduce wages at work, and reduce people's quality of life [78,79]. However, several studies in the USA, Poland and Saudi Arabia found no significant direct effect of COVID-19 on quality of life in students or adults [23][24][25]. The results of the present study corroborate the findings of previous studies. We believe that the reasons for this result are the following: On the one hand, the majority of Chinese football referees consider refereeing their second career. Of the 307 referees included in this study, only 12 were full-time referees. Therefore, although the COVID-19 lockdown has suspended all sporting events and reduced the salaries of football referees, they may still have income from other professions, so they are not under great economic pressure. On the other hand, Chinese football referees have a special working environment and work nature, and they need to bear great physical and psychological pressure when they are working. However, the COVID-19 lockdown allows them to rest at home, which relieves their physical and mental pressure to some extent, so it does not have a significant impact on their quality of life. The results of this study show that occupational stress plays a mediating role be-tween COVID-19 lockdown and the quality of life of Chinese football referees, that is, COVID-19 lockdown affects their quality of life through occupational stress. This is consistent with the results of previous studies. The COVID-19 lockdown has shut down most businesses and forced employees to rest or work from home, which in large part reduces their work skills. Therefore, in the early days of returning to work, occupational stress occurs due to the inability of physical conditions or professional skills to adapt to occupational requirements [80,81]. The results of this study reinforce the theoretical model of stressors proposed by Robbins, that is, when people feel the pressure brought by the environment, organization, or individual, they will have some physical, psychological, and behavioral symptoms [31]. Football referees' professional skills decline due to a lack of organized training and refereeing experience when they are isolated at home. They are worried that they cannot adapt to the high-intensity and high-pressure working state, which will cause occupational stress. Occupational stress can directly affect people's quality of life, leading to negative physical and psychological consequences such as migraines, insomnia, anxiety, and depression [82] and reducing people's quality of life [43,83]. The results of this study showed that job burnout played a mediating role between the COVID-19 lockdown and the quality of life of Chinese football referees, that is, the COVID-19 lockdown affected their quality of life through job burnout. This is consistent with previous research results [51,52,84]. The results of this study strengthen the job demand-resource model [50]. When the job resources cannot match the job demand, employees will have job burnout, which leads to physical and mental health problems, low job satisfaction, and decreased quality of life [85]. COVID-19 has had a great impact and influence on the sports competition industry in China, changing the work environment and status of sports-related staff greatly. Some of the most influential companies have even resorted to layoffs or salary cuts to cope with the crisis. On the one hand, for football referees, the COVID-19 pandemic has changed their work status, making them change from dynamic work to static work at home. The huge work change makes them feel unadaptable and causes job burnout. On the other hand, the COVID-19 lockdown leads to a decline in their physical fitness and professional skills. In the early stages of the resumption of sports competitions, their work ability fails to meet the job requirements, resulting in low personal achievement and job burnout, which further affects their quality of life. Finally, this study proved the chain-mediating effect of occupational stress and job burnout between the COVID-19 lockdown and the quality of life of Chinese football referees. This is also consistent with previous research results [59,86]. Job burnout is caused by the long-term accumulation of occupational stress. When employees experience job burnout, they will lose enthusiasm for work, have low work efficiency, and even have the intention of absenteeism and resignation [86]. At the same time, job burnout will also increase people's anxiety and depression symptoms and harm their physical and mental health and quality of life [64,87,88]. Affected by COVID-19 isolation, football referees' working ability decreases, which does not match their actual working ability, thus generating occupational stress. Long-term occupational stress leads to job burnout, which further affects their physical and mental health and quality of life. To the best of our knowledge, this is the first study on the impact of COVID-19 quarantine on the quality of life of football referees in China. This is mainly because, on the one hand, the number of football referees in China is relatively small compared with other professions. According to statistics, only 32 new international level referees were added to the Chinese Football Association in 2023. Therefore, it is not easy to recruit a large number of football referees as research subjects. On the other hand, football referee is a very important and indispensable role in every football match. However, most of the current research mainly focuses on football players and ignores the importance of football referees. Therefore, our study enrich the stressor theory and the job demandresource model, fills in the relevant research on Chinese football referees, and explores their occupational stress, job burnout and quality of life according to the reality of COVID-19 isolation, so that people pay more attention to the special group of referees. This helps to provide a theoretical basis for government departments and relevant organizations to take corresponding measures to reduce the occupational stress and job burnout of football referees during and after the COVID-19 quarantine, and to ensure that their quality of life is not affected by the COVID-19 quarantine. In addition, we further explore the influencing mechanisms in the four dimensions of quality of life . Among them, the physical domain included body pain, sleep, daily life and work ability satisfaction. Psychological domains included enjoyment of life, attention, depression, etc. Social relationships include interpersonal relationships, sexual life, and support from friends. Environmental fields include living conditions, medical care, transportation, money, etc. Our results find that the chain mediation model is also valid on these four dimensions. Therefore, alleviating the work stress and/or burnout of football referees can reduce their physical and mental injuries, promote physical and mental health, and improve their social relationship satisfaction, life satisfaction, and well-being. This will play an important positive role in improving the health and wellbeing of Chinese football referees. There are also some limitations to this study. First, the study is cross-sectional and cannot explain cause-andeffect relationships between variables. Therefore, we hope that future studies may consider using longitudinal research methods to further explore Secondly, this study used an online questionnaire platform and self-report to collect data. In the future, it is hoped that researchers can conduct research using more objective and multi-angle methods. In addition, our study explored the impact of the COVID-19 lockdown on the quality of life of Chinese football referees from the perspective of occupational stress and job burnout, and there are many unexplored factors. It is hoped that the next research can explore more mediating or moderating variables and enrich its mechanism of action. --- Conclusion Based on the stressor theory and the demand-resource model, this study takes Chinese football referees as the research objects to explore the impact of COVID-19 lockdown on their quality of life and its mechanisms. The results showed that the COVID-19 lockdown had no significant effect on the quality of life of Chinese football referees, but it could affect the quality of life and the four dimensions of the quality of life through occupational stress and job burnout, respectively. In addition, it can also influence the quality of life and its four dimensions through the chainmediating effect of occupational stress and job burnout. Therefore, this study provides a theoretical reference for helping Chinese football referees improve their quality of life after the COVID-19 lockdown ends. • fast, convenient online submission • thorough peer review by experienced researchers in your field • rapid publication on acceptance • support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year --- • At BMC, research is always in progress. --- Learn more biomedcentral.com/submissions Ready to submit your research Ready to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from: --- --- --- --- --- Competing interests The authors declare no competing interests. ---

Background COVID-19 lockdown measures have had a great negative impact on the development of sports competition in China, as well as on the quality of life of football referees. This study aims to explore the impact of lockdown measures implemented in response to the COVID-19 pandemic on the quality of life of football referees in China and its mechanism of action.The Impact of Event Scale-Revised (IES-R), the Effort-Reward Imbalance Scale (ERI), the Maslach Burnout Inventory General Survey (MBI-GS), and the World Health Organization Quality of Life Brief Version (WHOQOL-BREF). The scale was used from August to September 2022. Using an online questionnaire, 350 questionnaires were sent out and 338 were returned, for a return rate of 96.57%. Invalid questionnaires were excluded, and 307 football referees with referee grades in 29 provinces registered with the CFA were surveyed. SPSS 24.0 and Mplus 8.0 were used for data analysis and structural equation model testing in this study.The results showed that the COVID-19 lockdown had no significant impact on the quality of life of Chinese football referees. However, the COVID-19 lockdown can affect the quality of life of Chinese football referees through occupational stress or job burnout. Occupational stress and job burnout also play a chain intermediary role between the COVID-19 lockdown and the quality of life of Chinese football referees. In addition, this study further explores the quality of life by dividing it into four dimensions (physical, social, psychological, and environmental). The results show that all four dimensions satisfy the chain mediation model.Therefore, the quality of life of Chinese football referees can be improved by reducing their occupational stress and job burnout during the COVID-19 lockdown.

Introduction Many computational social science projects examine online discourse surrounding a specific trending topic, such as political events, natural disasters, or sporting matches. These works often involve the acquisition of large-scale corpora relevant to the event in question to analyze aspects of the response to the event, often with a focus toward social media. However, existing methods for the acquisition of these events come with trade-offs. Commonly, keyword searches are used , which present a choice between high precision and recall . One common method of keyword searching, specific to Twitter, is the use of hashtags. However, hashtag-only searches can lead to low recall . Crowd sourcing is an effective way to filter corpora , though it can be expensive both monetarily as well as in terms of time spent. This work proposes a method for automatic and accurate ad-hoc retrieval of comments discussing a trending topic from a large corpus using only a handful of seed news articles. Using a Siamese architecture and triplet loss, we jointly embed news articles and social media posts with the objective of minimizing the distance between the embeddings of each article and its relevant posts. This allows the automatic filtering of corpora by selecting comments most similar to news articles describing the event or topic of interest. The asymmetric lengths of comments and news articles pose a challenge for Siamese architectures. We propose a novel solution using a sparse attention mechanism, which allows the network to attend only to the most relevant parts of the input, easing the asymmetry in length. We make our code publicly available 1 . --- Related Work The specific task of matching articles and social media comments has received limited attention, especially in recent years. Some early works focused on social content alignment, the task of aligning comments to specific sentences within articles. Latent Dirichlet Allocation and several extensions, such as the Document-Comment Topic Model and Specific-Correspondance LDA , were used to provide interpretable alignments of comments to the most relevant segments of a news article. However, binary classification with feature engineering was seen to outperform these methods . Similar methods have been employed for the task of matching tweets to news articles. proposes a graphical weighted matrix factorization approach while also contributing a large-scale dataset similar to ours. Recent work using this dataset proposes an interactive attention mechanism to match tweet-article pairs . These works find the most relevant news article for a particular tweet, rather than vice versa. The intent of our work is more similar to , which identifies the most relevant tweet for a given news article using binary classifiers as well as semantic similarity. Little has been done to apply more recent advancements in deep learning to this task. This is likely due to the large computational overhead in training over corpora of news articles, which consist of thousands of tokens each, as well as the inherent theoretical challenges these methods face in processing long documents. These challenges have inspired creative solutions, such as segmenting long documents into individual sentences, hierarchically processing each sentence, and performing an aggregation step . Alternatively, presents an approach using Graph Convolution Networks on concept-interaction graphs to match pairs of news articles. While this is an effective method, the approach is restricted to pairwise classification, which creates a combinatorial explosion of pairs. Our work uses a Siamese architecture to perform retrieval using only cosine similarity. --- Methodology --- Task definition We use a large corpus of tweets which share links to news articles published by CNN and the New York Times . The corpus contains 34, 888 tweets which link to 12, 704 unique articles. While the goal of the original study is to find the most relevant news article for a given tweet, we are interested in the reverse; finding the most relevant tweets for a given news article. We say that for each tweet-article pair , T is relevant to A, and any other tweet T ′ not paired with A is irrelevant. --- Notation We refer to vectors in bold , tensors in capitalized bold , and scalars in standard font . We define an encoder as a deep neural network which maps a sequence of S word embeddings [e 1 , e 2 , . . . , e S ] to either an output sequence of D-dimensional hidden states H = [h 1 , h 2 , . . . , h S ] or a single D-dimensional representation H . --- Objectives We wish to use a Siamese network to jointly learn fixed-length embeddings for each pair, minimizing the distance between them using triplet loss. Projecting A and T into a common latent space allows us to compare the similarity of documents from vastly different domains . However, doing so requires an encoder capable of solving several challenges pertaining to document length. Noise. News articles can be in the order of thousands of tokens, and they often discuss multiple different topics . The asymmetric length of tweets relative to the articles suggests that tweets rarely discuss the entirety of the article's content, making much of the article irrelevant and perhaps even adding additional noise. As such, it would be useful for an encoder to be able to filter out this noise and focus on only the most important input tokens. Efficiency. Using large batch sizes creates more informative triplets , which is constrained by the already-high memory usage of processing thousands of tokens at once. These concerns are accentuated by the computational demands of the attention mechanism. While attention is more effective than other methods for modelling long sequences, its O complexity will exhaust reasonable resources with such long documents. As such, we require an encoder capable of efficiently processing long documents without sacrificing quality in the process. --- Blocking out the noise We begin by confronting the theoretical challenges of modelling long documents, such as the ability to capture the long-range dependencies and focusing only on crucially important tokens. Attention-based architectures have shown to outperform alternative candidates for these challenges . However, certain models such as BERT can be computationally intensive and impose maximum token lengths, which prevents their use. An additional problem for attention-based models introduced by such long documents is that they may struggle to identify vital portions of the text. For example, consider the attention mechanism and its multi-headed extension : Attention = softmax)V a i = Attention MultiHeadAttention = [a 1 ; a 2 ; . . . a h ] Where the parameters W Qi , W Ki , W Vi ∈ R D are trainable and f is a function which computes the similarity between each entry in Q and K. One such function is cos = QK T Q ⋅ K T , which is known as cosine attention . Crucial to the attention operation is the softmax function: σ i = e zi ∑ S j=1 e zj This produces an S-length vector with a sum of 1, where each z i is a weight for each token in the input document. The operation softmaxV is equivalent to taking a weighted average of each token embedding in V . Note that softmax has full support i > 0), which means that even unimportant portions of the input document will still receive non-zero weight . As we noted earlier, our documents are very long and many of the words could be unimportant to the output, which makes it highly difficult for softmax to filter them out without assigning any weights of precisely 0. In fact, we observe a negative correlation between S and E [σ i ] -that is, as documents grow longer, the expected weight of a given token decreases. We provide a brief proof in appendix A. This is problematic, as it will be difficult for the most important tokens to stand out in such long sequences like news articles. As the value of each attention weight decreases, the distribution becomes more uniform, and the operation becomes equivalent to simply taking the mean over all h i ∈ H, many of which should have been filtered out. To counter this problem, we look toward the growing family of sparse activation functions. Figure 1 demonstrates a comparison of self attention using softmax versus one such sparse function, known as sparsemax . While both activations identify important tokens in a sequence of 5, softmax approaches uniformity for the sequence of length 25 while sparsemax still identifies important tokens. In particular, we replace softmax with the αentmax activation function, a controllably sparse alternative , and we use a unique trainable parameter α h for each attention head h. This is known as adaptively sparse multi-head attention, which addresses our first objective by allowing each attention head to learn an optimal level of sparsity . This allows each head to learn which segments of the input sequence to filter, reducing the noise introduced by long input documents. --- Improving efficiency Next, we address our second objective, which requests an encoder capable of efficiently processing long documents without sacrificing quality in the process. Irrespective of the activation function used, the O complexity of a standard Transformer layer is prohibitively expensive for documents thousands of tokens long. As such, we require a way to model long-range dependencies more efficiently than a standard Transformer. For this, we use the Star Transformer, a simple and efficient extension of the standard Transformer capable of learning many of the same semantic relationships and long-range dependencies . Initially, each h i = e i , and a message-passing relay node s is initialized as the mean of all e i . For each embedding e i , its immediate c neighbors and the relay node s are used to form a new representation h i . This message-passing mechanism enables the learning of long-range dependencies in linear time, as each attention operation only considers the c immediate neighbors of each token . C i ∶= [h i-c ; . . . h i ; . . . h i+c ; s] h i ∶= MultiHeadAttention After all i operations, we then update the relay node as s ∶= MultiHeadAttention where H = [h 1 ; h 2 ; . . . h n ]. The authors find that performing T iterations of these operations enables re-reading to more effectively capture long-range dependencies, though additional iterations only marginally improved performance in our experiments. To encode the output sequence H to a fixedlength vector, we take the maximum over each embedding dimension and average it with the final state of the relay node, computed as max+s 2 . passed through the encoder, producing fixed-length vectors f t and f a . These embeddings are directly passed to the objective function, triplet loss , formulated as: --- Siamese L = max Where f t ′ is an irrelevant tweet mined using the multi-similarity method , and α is the margin. This minimizes the distance between the embeddings of articles and their relevant tweet. Figure 2 shows the t-Stochastic Neighbor Embedding projection of the learned embeddings for a sample of tweets which reference the top-10 most shared articles in the dataset. The result is that tweets referring to the same articles are tightly clustered in latent space. We call our resulting model the Adaptive Siamese Transformer . 4 Experimental Results --- Evaluation Criteria The goal of our work is to enable the automatic filtering of a corpus of tweets using news articles as seeds. We assume that it is cheap to collect tweets, but expensive to annotate them, and that an ideal model identifies relevant tweets while returning as close to 0 false positives as possible. Precision, a common metric for many information retrieval tasks, reflects our wish to minimize the number of false positives. A model that retrieves exclusively relevant documents will have a precision of 100%. However, this could be achieved by simply returning a very small amount of relevant documents. We ensure that a reasonable number of documents are returned by using r-Precision as our evaluation metric, which computes the precision after r documents are retrieved. We also report several other metrics for additional comparison. --- Inference Process For evaluation, we hold out approximately 3300 samples as our test set. The model returns an embedding for each news article f a and tweet f t . The relevance score of a given f a i to a given f t j is defined as their cosine similarity. --- Training Configuration We train Siamese networks on a large dataset of tweet-article pairs using three additional encoders as baselines, including Convolutional Neural Networks , Gated Recurrent Units , and Bidirectional GRUs as benchmarks. Each network uses 300-dimensional pre-trained GloVe embeddings . Triplet mining was performed using the pytorch_metric_learning library , and experiments were conducted with the AllenNLP library using four NVIDIA V100 GPUs on Google Cloud Platform. All configuration details are available on GitHub. Evaluation #1. We report the r-Precision for each baseline encoder, which is the precision after having retrieved r documents. For each r, we retrieve the r highest scoring tweet-article pairs by cosine similarity, and compute the precision. This captures both the quality and quantity of documents retrieved by each model. All models decrease in precision as they retrieve more documents, as is expected . The GRU-based framework quickly falters in performance, demonstrating the challenges recurrent models face with long sequences. Bi-directionality appears to help, but the most competitive baseline was clearly the CNN-based framework. We posit that CNNs' ability to identify the most important n-grams using global max pooling provides the filtering ability we describe in our first objective. Our model performs the best at higher quantity thresholds, significantly out-performing the recurrent models. It is possible that the sliding-window approach of the Star Transformer could lead to similar behavior as CNNs, a possibility we leave to be examined in future work. Evaluation #2. We also report mean r-Precision , Mean average precision , and area under the Receiver-Operating Curve . mRP is simply the r-Precision over all thresholds in Table 1. mAP and AUC-ROC are calculated using the scikit-learn library . Our model outperforms the three baselines in each metric. --- Results --- CNN GRU Learned sparsity. Following the training process, we examine the α values learned by each attention head of the Star Transformer. Values closer to 1 will lead to attention weights closer to those produced by softmax, while values closer to 2 will be similar to sparsemax, and a value of 1.5 is equal to 1.5 -entmax . The star attention heads are used to update the relay node, while the ring attention heads are used at each context window. Overall, it appears that the ring attention heads learn a diverse set of alphas, allowing for varying levels of sparsity in the representations of each context window. Heads 4 and 5 approach sparsemax, while heads 3 and 6 remain relatively close to softmax. The α values for the star attention heads were more tightly bound, but heads 1 and 3 were still quite sparse, exceeding the sparsity of 1.5 -entmax. --- Case Study Finally, we present a case study applying our model to a corpus of tweets about a terrorist attack which took place in Toronto, Canada in April 2018. We computed the cosine similarity of 100 manually annotated tweets' embeddings to that of a news article written shortly after the attack2 . As shown in Figure 4, with a retrieval threshold of cos ≥ 0.7, our model was able to minimize the number of false negatives without greatly diminishing the quantity of tweets retrieved. As seen in Table 3, sorting the tweets by cosine similarity showed results which may suggest that the model was able to learn which tweets are more relevant than others , though we note these results are heavily anecdotal. We share these results to demonstrate potentially useful applications of our model. For example, a project which requires at least N relevant tweets and precisely 0 irrelevant tweets necessarily requires human annotations. Our model could significantly decrease the financial cost of collecting annotations by presenting the tweets in order of estimated relevance , minimizing the quantity of tweets that must be shown to annotators until N relevant tweets are found. Yesterday was a deeply sad day for the city of #Toronto and our hearts go out to the victims, the families and anyone affected by the tragic incid... --- 0.8686 --- ⋮ ⋮ Incel or MGTOW Facebook groups banned me from their Facebook groups all because they also hate not just women. --- 0.4311 Une pense pour le tragique vnement Toronto 0.3877 Stay strong Canada -we are with you 0.3875 It is both wrong and unhelpful to cast the incel phenomenon as some kind of dark internet cult. This is garden variety misogyny and rape culture w... --- 0.3797 Reading that InCel "female ratings card" post going around and am increasingly beset by a burning curiosity as to where lesbians fit into their co... --- 0.3361 Table 3: The most and least similar Tweets to a news article written after the attack. --- Discussion In conclusion, we present a novel approach to article-comment linking using a Siamese architecture and triplet loss. We encode pairs using Adaptive Star Transformers, an efficient Transformer using adaptively sparse attention to filter irrelevant information from the input sequences, which we show outperforms several other encoders in a Siamese framework. This model could allow other researchers to eliminate or vastly reduce the cost of filtering corpora. --- Appendices A Softmax Expectation We will show that an increase in S, the length of a document, can be expected to diminish the weight of each token in the softmax step of the attention mechanism. To demonstrate a decrease in E [σ i ] with S, we need only show an increase in the expectation on the denominator ∑ S j=1 e zj , which we refer to as expsum. Using cosine attention, let z = cos. Since cos ∈ [-1, 1], let each z j be an independent random variable drawn uniformly from U. It follows that all e zj ∈ [e -1 , e 1 ]. The expectation on expsum then becomes: ≈ 1.1752 ⋅ S This demonstrates that E [expsum] increases as a function of S. As stated previously, an increase in E [expsum] decreases σ i . This dictates that σ i must decrease when S increases. Therefore, an increase in the length of a document will decrease the expected attention weight of each token. ∎

Many computational social science projects examine online discourse surrounding a specific trending topic. These works often involve the acquisition of large-scale corpora relevant to the event in question to analyze aspects of the response to the event. Keyword searches present a precision-recall trade-off and crowd-sourced annotations, while effective, are costly. This work aims to enable automatic and accurate ad-hoc retrieval of comments discussing a trending topic from a large corpus, using only a handful of seed news articles.

High adolescent fertility and late marriage among Black South Africans underlie high rates of "non-marital" 1 fertility. Although the median age at first marriage is 27, almost one-third of Black women have a birth by age 19 2 . Black South Africans are often treated as an undifferentiated whole, resulting from the legacy of apartheid and assumptions about shared cultural and ethnic attributes . However, some important cultural and regional differences do exist, for example in the management of non-marital fertility. By management, we mean the ways young women and their families respond to a nonmarital birth. Management thus involves the practices which legitimise a non-marital birth: gaining recognition of a woman's union with the child's father or integrating the child into the mother's family. In this analysis, we examine the similarities and differences in the management of non-marital fertility among young women in two rural and predominantly Black communities in two South African provinces: KwaZulu-Natal and Mpumalanga. Through comparative analysis of qualitative data, this study offers a dynamic approach to understanding the management of non-marital fertility, attending to the interactions between established ideas about kinship and union formation with contemporary constructions of social reproduction. We contribute to discussions of fertility and union formation in southern Africa in several ways. First, we provide new insights into how young women and their partners and families engage with non-marital fertility, a relatively common occurrence. Second, we consider sociocultural and regional differences within one race category3 in South Africa -a topic that has received scant attention. Third, we offer a dynamic cultural approach to the comparative study of fertility and union formation that privileges smaller scale heterogeneity and variation, via an interactive cultural framework comprised of likely influences on fertility and union formation. --- Conceptual framework Fertility research usually treats Black South Africans as an undifferentiated, culturally homogenous group resulting in race being the most common basis of comparison . The conflation of race and culture in studies of non-marital fertility in South Africa has been described as a racialising project that exoticises the category of Black with immutable notions of race, 'tradition, ' and culture . Critics argue that the use of race as a proxy for culture creates homogeneous and static cultural understandings that mask important differences between groups and changes over time . Moreover, it misses a critical observation that the management of non-marital fertility reflects a wide range of historical and cultural influences, including colonial administrative and legal structures, Christian beliefs and practices, and contemporary reification of 'traditional' cultural practices . In an effort to correct this representation, we adopt Spillman's broad definition of culture as "processes of meaning-making" that are fluid and active. We emphasize culture as a dynamic process by employing an interactive model of two critical factors that underpin the unique strategies employed by women and families to manage non-marital pregnancies and births in two South African communities. These factors are: prevailing sociocultural norms towards union formation and non-marital fertility; and life aspirations and the value of education. Prevailing sociocultural norms refers to shared beliefs and practices about the timing and process of union formation especially in relation to fertility. We pay particular attention to the legitimisation of non-marital births to preserve moral codes of behaviour. We also examine how exposure to knowledge about HIV/AIDS influences decisions on union formation and childbearing. Life aspirations and the value of education pertains to how young women and their families view connections between the completion of secondary schooling and other milestones, namely, forming stable relationships and having children. We also examine the tensions inherent in satisfying multiple criteria of respectability, such as getting married and attaining education. While privileging the local context, we recognise that broader historical and global factors -economic constraints, media exposure, and experiences of HIV/AIDS -have resulted in more similarity than difference in certain areas. --- Data The qualitative data in this study were collected through long-term engagement and observation in two communities: the Agincourt sub-district of Mpumalanga Province; and the Hlabisa sub-district of KwaZulu-Natal Province. While the dominant ethnicity in Agincourt is Tsonga4 , the site in KwaZulu-Natal is almost exclusively Zulu. The Agincourt data were collected in [2003][2004] and again in 2010 while the Hlabisa data were collected between 2000 and 2005. The first wave of the Agincourt data comes from the Children's Social Connections and Well-Being study and includes detailed data on 19 young mothers, their families, and children. The second set of data is comprised of 4 focus group discussions and 61 in-depth interviews with women aged 18-75. Topics include reproduction, HIV/AIDS, work and education, and ideas about 'modern' women. The Hlabisa data come from the project, Gender and the Social Dynamics of Adolescent Risk, which included young men and women aged 14-24 years from five communities. This analysis includes data from 30 peer group discussions and 12 in-depth interviews. Sexuality, HIV, and pregnancy-related behaviours were discussed in single-sex groups that met six times over a four to six month period. Data are also included from two FGDs with teenage mothers on their pregnancy and parenting experiences and the impacts on schooling and employment, and from a study of gender, relationships, and HIV risk among 18-24 yearolds, where pregnancy was extensively discussed. In Hlabisa, all interviews were conducted in isiZulu and in Agincourt, in xiTsonga. In both sites, interviews were translated and transcribed by native speakers, and then coded using NVIVO software. Data analysis was based on various levels of coding and the extraction of relevant patterns for comparison. We used a comparative analytical framework to guide the data analysis, seeking to apply the interactive cultural model outlined above to understanding factors influencing the management of non-marital fertility in the two sites. To do this, we followed a two-step approach: first, main themes for each site were elucidated and second, these themes were used as the basis for the comparative analysis across the two sites. In the comparative analysis, themes from each site were consolidated into the main themes of: prevailing norms toward union formation and nonmarital fertility; and life aspirations and the value of education. Each of these main themes was then divided into sub-themes, which represent either a common theme across the two sites or a dominant theme from one site. In this way, we engaged two distinct but complementary processes of data analysis that reflected the study's interactive cultural model. Quotes and vignettes are presented to lend emphasis to particular ideas and comparisons when appropriate. --- Similarities in political economic context Both sites are in rural areas neglected under apartheid, which functioned as labour sending areas to Johannesburg and other large cities, generally for employment in mines . Now, both sites are connected to larger towns through improvements in roads and public transportation. School quality is poor and viewed as an obstacle to accessing good jobs; better-off families may send children away to private boarding schools. Employment opportunities in both sites are mainly found in small scale commerce, teaching, nursing, and tourism . Informal, non-school-based educational and training opportunities have boomed recently, reflected in the growth of driving school businesses, computer training centres, and other skills training, including as lay health workers in HIV and AIDS-related care. Despite these changes, young people in both sites face enormous challenges in finding local employment even with a strong educational background. In order to work, young people, particularly men, may move to urban areas, while those who cannot find work are likely to remain in rural areas but may depend on financial support from family or partners. Thus, young women may keep closer links to their homes and the local political economy, while young men may make a new start and return home less often. Yet despite these similarities, the ways in which young people and their families make decisions about the management of non-marital fertility are not necessarily the same, as discussed below. --- Prevailing norms towards union formation and non-marital fertility --- Maintaining control over reproduction Most respondents in both sites say that pregnancy should come after some formal acknowledgement of a union, such as payment of bridewealth or lobola, as discussed below by two women ages 27 and 28, respectively in Agincourt: Busi: Lobola should be the first priority. Other guys will know that you are Mrs. So and So. They will respect you rather than getting a child. Even the families cannot start a relationship because they don't know each other. What if that guy regrets? Lobola should be first, therefore children at last. Sizakele: Lobola is not valuable today, because even married woman fail to respect their marriages, they tend to have extra affairs outside their marriages and if your husband can find you he can kill you.[] Despite a lack of consensus on the value of lobola and the financial difficulties it causes men, many women remain positive about this practice. In Hlabisa, young women often focus on social expectations around their relationships with men: introducing a young man to the family, often through a ceremony known as ukumiso iduku -'raising the flag'; followed by gifts ; and formal recognition of the relationship, after which young people say ngiqomile, 'I am committed'. In recent years, as marriage has become less common, full lobola payments may never occur, thereby reinforcing the symbolic value of such commitment procedures. This is demonstrated in the poignant words of a 19 year old mother, Lindiwe, in Hlabisa: I do not know whether it is because we have grown, we even have a baby in this relationship that is loved by both my family and his family. Because of that we had no choice but to introduce each other to our families because there was no need for any more lies. He also loves me so much, and I love him too, before, we used to do things very secretively. Also at that time, he was unable to show me how much he loves me because we were treating everything very confidential. The young woman's references to 'any more lies' and 'doing things secretively' reflect the extent to which young people rely on culturally sanctioned procedures to navigate relationships, particularly when a pregnancy is involved. Familial recognition of a partnership permits a young couple to have a socially sanctioned relationship without social consequences, avoiding embarrassment to the families, especially the girl's . At the same time, non-marital pregnancy remains a stigmatised and undesirable outcome, especially for young women still in school, as indicated in the following interchange: Gugu: They take it as a bad thing. When I was pregnant some of the parents told their children not to play with me or go with me because I was going to teach their children bad things. --- Laughter Nandi: My community talked a lot about a girl who is pregnant. Most mothers wouldn't allow their children to talk to me because I was pregnant. Whenever I was talking to someone, sometimes they would call her and tell her not to talk to me because I was going to teach her about boys. [16][17][18][19]Hlabisa] Paying damages or inhlawulo constitutes another possible step in legitimising a non-marital pregnancy. Damage payments -culturally sanctioned means of compensation for premarital pregnancies in many African communities -are made by the boy or his family to the girl's family. These practices exist to a greater or lesser extent in both sites but financial challenges often make formal payment very difficult. Thus, we could not identify one case where a formal damage payment was made in Agincourt. In both sites when damage payments are not forthcoming, young women's families often seek alternative means of compensation, especially to ensure that a child is properly incorporated into an ancestral lineage. To avoid such responsibilities, young men may deny paternity, thus releasing them from the obligation of paying damages and from any further contact with the mother or the child . In sum, these data suggest that sociocultural practices aimed at regulating young people's relationships and fertility remain important in Hlabisa, primarily through pursuit of more formal links to the father's family. However, neither structured engagement processes or more informal means leads predictably to formal marital unions. Yet non-marital pregnancies are increasingly one of the few readily accessible means of obtaining adult status for young people in both sites even if these pregnancies are frowned upon by the larger community. --- Responding to non-marital childbearing Our data suggest differences across the two communities in fathers' behaviours following a non-marital pregnancy, as shown in the following statement made by Nomvula, a teen mother in Hlabisa He told me to come to his home so as to inform the parents [about the pregnancy]. We went there …They called him and ask him if he knew about me. He told them that I was his girlfriend. Whenever I got sick, he would give me money to go to the doctor. Even after delivery, he bought everything for the child; even now he still supports the baby. My parents buy whenever they feel like but it's not their duty to buy my child food and clothes.] This young woman exhibits a sense of relief that her boyfriend 'recognised' her and did not deny the child, and also continued to support her and the child after the birth. At the same time, she is left to juggle between her parents and her boyfriend with regard to economic support for the child. In contrast, many boyfriends in both sites did not support their offspring, as in the following story recounted by Precious, aged 28, from Agincourt: My child's father was promising me heaven and earth before I fell pregnant. He was having a plan of the house he was going to build for us. But after a year, he dumped me to another woman. What I have learned is that if you are having a boyfriend, don't get a child faster. You can stay for more than ten years. If he is serious he will wait for you. Again look at your background and his own background; therefore take a decision. Even when partners do not live up to expectations, this participant and others like her use acknowledgement of paternity as a critical means of legitimising non-marital pregnancies. In Agincourt, the importance of recognising the union has been largely replaced with recognition of the pregnancy by the child's father, while in Hlabisa, recognising the union remains a key part of the process of legitimising the pregnancy. For reasons that remain unclear, paternal acknowledgement in Agincourt appears to symbolise a different and somewhat more contemporary approach to marriage and partnerships; it may also be the only way of gaining recognition of the child from the father. In Hlabisa, more emphasis is placed on the young partners' families and carrying out cultural practices that ultimately protect both the woman and child from social retribution. In both sites, families of young mothers and their partners play an important role in supporting the child and sometimes the young couple. In Agincourt, most young women have their first child at their parents' home and receive the most help from their own mothers , which appears to be a relatively new pattern signifying a notable shift in childrearing responsibilities to maternal kin. However, young mothers and their families attempt to make connections to young women's partners and their families in order to ensure financial support and to bolster legitimacy through an acknowledgement of paternity . The level of support from fathers and their families varies enormously, from the sporadic provision of clothing and food to consistent support for the child. Even though women may desire to stay connected to their child's father, they are often ambivalent about paternal involvement, as made clear in the following conversation between two mothers, ages 16 and 19 in Agincourt: Ayanda: It is difficult because you find me as the mother and the child's father do not agree on who the child should stay with, at the end you find that I am forced to give the child to his father. Only to find that the father is married to another woman who is going to live with my baby. My heart will always be painful, thinking that the woman is ill-treating my child, sometimes beating or not giving him enough food. Nobuthle: Sometimes you find that the child is left in a family where they are careless about kids. They don't care where they play and who they play with. [Young mothers, ages 16 and 19, Agincourt] Both statements reflect the bind that young women find themselves in. In order to gain financial support from the child's father and access child care support from the father's family, young mothers may have to accept whatever conditions are offered. While many families provide a needed safety net for young people and their children, often they cannot provide such support, as indicated below: Lazarus : But whenever a boy can impregnate someone else, that child [boy] will be forced to leave school and go to look for a job because his father won't be able to support the wife [the pregnant woman] and the [future] child. Nomazano : There is a huge difference now. Before I had a child, I could ask anything and they would do it for me because I was the child they love. But since I have a baby, they told me that they are not responsible for me; the only person who has to look after me was my boyfriend. From then I learned that I have to look for a job so as to take care of the child, something I never thought I would do before I got pregnant. In both settings, the young mother's family usually bears the bulk of responsibility for her child. Even when young women and their families attempt to maintain relations with the child's father, often explicitly hoping that marriage will occur, a non-marital pregnancy strains many relationships. In both sites, economic considerations are usually paramount. This, in turn, necessitates one or both young parents to work to support the child, which may geographically separate them for periods of time. --- Knowledge about HIV/AIDS Exposure to knowledge about HIV/AIDS is often cited as a critical factor enabling young women to exert more control over their reproductive decision-making and protect themselves from HIV. Moreover, given the high HIV prevalence rate in South Africa -17.3% among adults age 15-49 -it is likely that it would also influence how young women and their families view union formation and non-marital pregnancies. Indeed, a common refrain in both sites highlights the need to educate children about sexuality -especially HIV -as made clear in the following statement from a 52 year old man, Geoffrey, in Agincourt: Children should also be taught the good way of handling themselves, behaviour and good manners. They should also be taught about the AIDS epidemic we are facing today. There is also some evidence that the fear of infection is motivating women to end unions: Like my child's father, I am the one who has told him to stop seeing each other because he was having another love affair. Sometimes he will come during the night. You will accommodate him and there are illnesses nowadays. He will end up coming with them to infect you while you are staying waiting for him. [Dudu, aged 20 Agincourt] Despite such stated concerns, there is a notable lack of connection between HIV awareness and decisions around union formation and childbearing amongst young women in both communities. This is made clear in the following statement from an interviewer talking to a young mother, Sibonghile, in Hlabisa. If I remember very well in one of our discussions you said falling pregnant is better because you deliver and you relax but if you have AIDS you will end up dying. By presenting the two options of pregnancy and HIV/AIDS, this young woman appears to recognize the consequences of having unprotected sex. Yet, the prospect of becoming HIV positive does not seem to have motivated her to practice safe sex. In addition, it is, perhaps, not surprising, that she equates HIV/AIDS with a death sentence given the limited access to treatment in South Africa during this time. The following interchange among female focus group discussants in Agincourt suggests a similar disconnect. Nomthando: They [young women] lack knowledge. If a boy comes to share her, she only knows to say yes and the boyfriend will do anything he can. She is not able to say no as she doesn't take any decision. At any time and at any day the boyfriend feels he can have sex, she goes to him and she cannot regret. Joyce: She is still young and she doesn't know how to say no. All she thinks is that maybe it is the way to show your love. She doesn't know the after effects of sleeping with guys. The lack of an explicit connection between HIV and reproductive decision-making processes exposes inherent contradictions in people's attempts to configure new approaches to union formation and reproductive behaviour. For example, in both sites, young mothers were often conflicted about the value of having a migrant partner. While they clearly valued financial contributions to help support their child, they were also suspicious about their partner's faithfulness and associated HIV risks, a valid concern in these high HIV prevalence locations. While educational and employment aspirations provide new freedom to determine who to have a relationship with, for how long, and whether to have a child together, these may also put young women at a higher risk for HIV unless they prioritise safe sex as an important component of their relationships. In reality, young women in both sites appeared to have very little specific information about their personal prevention needs related to either pregnancy or HIV/AIDS, although general knowledge of HIV/AIDS is now very high . --- Life aspirations and the value of education --- Timing of life events Similar to other African settings, there is overwhelming consensus in both sites that completion of secondary education is an essential pathway to success, and an achievement that ideally should precede both union formation and childbearing . A young female respondent in Hlabisa, Thenjiwe, reflected on the importance of the proper ordering of life events: Well, I've always wanted to finish school before I can involve myself in relationships. So what's been happening is that I have been refusing all proposals from the boys. A similar sentiment was expressed by the following young man, Bandile, in Hlabisa: It will remain that way for me [not having a baby] until I feel that I have all that I ever wanted in life, having a good job, getting married and then I can have a child, not by mistake. I just want my education to come first without any interruptions [pregnancies]. Despite expressed intentions, in reality schooling is interrupted in myriad ways, due to family economic circumstances, school closures, transfers between schools, and pregnancies for young women. There is now a substantial amount of research that highlights the challenges that young women face managing schooling and parenting . As a result, despite recent government policies that set an upper limit for school completion, many rural young people continue schooling into their early twenties. Phumzile, a young woman in Agincourt described some of the complexities that may accompany young women's schooling experiences: One can be a failure if he/she starts engaging herself in relationships, like myself -I fell in love with a teacher at a very early age, I was fourteen years. He ended up marrying me, and my schoolmates were calling me Madam, and that thing irritated me. I was no longer happy at school; from there I hated to go to school. Overlap between union formation, pregnancy, and schooling is a realistic scenario as young women manage competing agendas. When this happens, the importance of schooling is usually reinforced by young women themselves and their families, as is evident in the following comments of Cecilia, an older woman from Agincourt: There are no good reasons either for stopping a child's education. If your child impregnates a girl than you must take full responsibility and if it is your child who has been impregnated you should look after the baby and let the child continue with her schooling. Indeed research shows that girls who have a functional support system are more likely to return to school . However, this is far easier said than done and the data from both sites indicate considerable challenges in satisfying these multiple and sometime competing agendas. The following is a FGD between teen mothers in Hlabisa: Andile: Me, I decided to stop schooling in March when I realised that I was pregnant. Duduzile:: The pregnancy affected me because I had to stop going to school in April because I was afraid that other students knew that I was pregnant… Khethiwe: I changed the school. … Nozipho: When I left school, everyone knew that I was pregnant even the teachers so I didn't want to go back. Focus group discussions with young mothers in Agincourt also highlight the challenges faced in returning to school following a pregnancy: Nkateko: Because I didn't have someone to take care of my child. I have wasted my time because of bearing the child. I have stayed for two years, taking care of my child. My mother said she will look after her if she is two or three years. Then when I look because that the time is come, I will not be able to go back to school. Nkhensani: I have stopped going to school after becoming pregnant. I didn't go back to school at all. I wanted to go back to school but my mother refused to stay with my child. Moreover, there is a sense of "wrongdoing" when a girl gets pregnant while in school: Thandi: Parents do not have to stop the child to go to school when she is pregnant. Parents have to talk to the child and when the child asks the parents to forgive her, the child should go on schooling. But if the child does not ask forgiveness, you can stop her and look after her child. [45 year old woman, Agincourt] The stress on forgiveness suggests that young people and their families believe there should be strong censure against engaging in sexual activities as a student and inconveniencing a family with an extra child to care for. --- Education, respectability, and marriage In Agincourt, there is notable ambivalence among the older generation about the role of education in shaping young people's attitudes towards union formation and childbearing: Girls who are educated are less likely to get married. Most girls who are educated think that they can survive even if they live on their own. Getting married is not what they usually do and they would just have partners, [Female age 55, Agincourt] When a man marries you while you are not educated he will leave you on the way. When he went to work and see that other men are working with their wives, he will come and divorce his wife at home. And he will start looking for a woman who is educated so that he can work with her. [Victoria,age 38,Agincourt] In this same context, completion of schooling is seen as important because of its potential to translate into a good job, thus rendering one a preferable marriage partner. Both men and women seek partners with education and money to help support the household. Therefore, young people have incentives to do well in school. However, because education and employment increase women's financial independence, they may offer reasons to avoid marriage. In Hlabisa, marriage represents an important life aspiration for both young men and women. Material characteristics are important, but young women are also looking for polite and respectful partners who conform to expected social norms. Since parents often oppose relationships, young people may seek to improve this situation by selecting partners who will be acceptable at home. This may be particularly important if a young woman envisions a future for the relationship, meaning her family would have to accept her boyfriend. Below, women aged 14-16 from Hlabisa describe characteristics of an ideal partner: Laughter Ntokozo: A boy who behaves well, who is clean, able to communicate with other people, and who loves other people. Mbali: I want someone who is active, handsome, dresses smartly, loves people, wears a smile every time and is a sweet person. … Sizani: Maybe at college or at university level and not a person who is not working. This list of fairly rigorous criteria reflects the idealism and romance surrounding ideas of relationships even with the recognition that attaining such ideals is unlikely. In Agincourt, both young men and women placed more emphasis on education and employment prospects as desirable qualities in partners. --- Discussion Using a conceptual framework grounded in an interactive model of culture, we set out to explore similarities and differences in the management of non-marital fertility in two Black communities in South Africa. In the context of a retreat from formal marriage and the limitations imposed by the local political economies in both sites, young people and their families engage in efforts to legitimise non-marital pregnancies and attain status. The two factors that we focused on: prevailing norms towards union formation and non-marital fertility; and life aspirations and the value of education have produced distinctive strategies in the management of non-marital fertility despite similarities in the political economic landscape in each site. In Agincourt, the formal processes of legitimising non-marital pregnancies have been largely abandoned, although they are still considered the ideal. Instead, importance is now often placed in establishing connections with the child's father as a means of social and financial support for the child. The focus seems to be more on securing support and paternal recognition for the child rather than on cementing the union between the young woman and her partner. In Hlabisa, formal processes for legitimising non-marital pregnancies through union recognition are still in place, although followed to different degrees. These processes serve to make the pregnancy respectable, which could mean sustaining the relationship with the child's father or accepting damages and legitimately raising the child within the mother's family. Although these routes are preferable, there are many instances where neither is followed and young women's families take responsibility for the child, a common situation in both sites. These differing strategies need to be understood in light of idealised and actual life trajectories . In both Hlabisa and Agincourt, education is a vital part of establishing a contemporary life trajectory, which ideally includes completing school, formalising a union, and only then having children . In both sites, young people have high expectations regarding secondary and tertiary education , which is portrayed as attainable by all in post-apartheid South Africa. Education is now widely available in both sites but does not provide young people with the background and skills they need to be economically successful. Although upwards of 85% now attend secondary school, less than half are able to pass the national post-secondary matriculation exam, which provides entry to universities . Secondary and tertiary level education is often constrained by family economic circumstances. In light of the retreat from marriage alongside high rates of non-marital pregnancies in both sites, our findings point to the fact that, intentionally or not, childbearing has become a means of achieving social goals, such as the transition to adulthood. Even while stating their desire not to become pregnant at a young age and prior to being in a well-established relationship, young people in our data acknowledge the social importance of parenthood and fertility, a point made in other literature . Thus, in the face of declining opportunities for marriage, childbearing appears to be playing an increasingly important role in social reproduction for young South Africans, especially women. A variant of Johnson-Hanks's 'vital conjunctures' idea about how young people's decisions reflect the careful management and timing of key life events such as pregnancy, schooling, and marriage, our findings suggest that young people in both sites, but particularly in Hlabisa, are attempting to reconcile what they perceive to be their normative obligations to their kin group with the reality which presents significant challenges to achieving this ideal. In this sense, kin identity continues to exert its influence, particularly in Hlabisa, similar to in other African contexts . This appears to be related in part to the ongoing influence of cultural ideals in Hlabisa , a process readily apparent in young people's discussions of sexuality and relationships, contrasted with the more rapid dilution of those ideals in Agincourt . While the constraints of the local political economy are similar in both sites, it appears that young people in Hlabisa are attempting to be more responsive to kinship obligations and cultural mores by gaining family approval of partners, paying damages , and avoiding communal sanctioning of non-marital births. In both sites, there is little evidence that knowledge of HIV/AIDS influences decisions about union formation or childbearing underscoring another point of tension in the ways young women and their families manage relationships and non-marital fertility. Moreover, young women in both sites are attempting to reconcile family and community expectations with educational aspirations and accessing good jobs. Our analysis suggests that there are subtle differences in the ways young people and their families view the value of education in each site. In Agincourt, education increases one's attractiveness to a potential partner but presents a dilemma for older generations who see it as a ticket to employment but also a potential threat to union formation and stability. In contrast, young women in Hlabisa value education and view it as an asset in seeking a marriage partner rather than a threat. In both sites, finishing schooling and finding viable employment are constrained by opportunities in the local political economy. Families recognise these constraints and are often willing to provide support, particularly to young mothers and children, where and when possible. Our interactive model of culture permits a deeper understanding of both the similarities and differences between the sites and the inherent contradictions that are apparent in young people's life trajectories . For example, the fact that more effort is made in Hlabisa to maintain formal practices compared to Agincourt may be a reflection of how Zulu identity is being reshaped in the post-apartheid ethnic mosaic to resist a national homogenisation of Black African identity , as well as historical realities in which Zulu cultural identity was promoted for political reasons and deeply entrenched . The Agincourt area has always been more ethnically mixed which, in turn, may entail more pragmatic and flexible approaches to addressing non-marital fertility. Such differences may have implications for intervention strategies aimed at school completion and delaying childbearing. It may be that, in Hlabisa, more effort has to be made to design programs that respect and make reference to prevailing cultural ideals and social norms, including the recognition of kin groups, whereas young people in Agincourt may be more receptive to strategies that target individual behavioural change. One approach currently being tested in the Agincourt area is a conditional cash transfer programme to help young women stay in school, thereby reducing the likelihood of early childbearing and HIV infection and increasing future economic potential . In both sites, the realities of the contemporary political economy related specifically to jobs and future aspirations, and more broadly to social disruption overwhelm other considerations. There is little doubt that, in both communities, resources need to be committed to the improvement of schools and the creation of employment opportunities to help young people achieve more positive life trajectories, including delaying childbearing. Our analysis focused on the perceptions and behaviours of young women and their families in managing non-marital fertility. There is a need for future research that focuses on similarities and differences in these processes by gender because of the centrality of fertility and early childbearing in young women and men's lives. Swartz and Bhana's research on young South African fathers represents an emerging body of work on fathers, paternity, and the role of families; however, more research is needed in this area. Our analysis suggests that demographic studies that attempt to understand differences only by race are very limited when it comes to the Black African population in South Africa. Treating the Black African population as an undifferentiated whole would miss important differences in the ways different communities have maintained, discarded, or reinvented cultural practices in the management of non-marital fertility against shared commonalities in structural disadvantage. Marriage remains an aspiration but no longer an achievable one for many young people. Within this context, non-marital fertility has a purpose and can be seen as a rational means of achieving adult status, and in some cases, of ensuring ongoing connection to family, community, and home. In this way, non-marital fertility may be seen as congruent with local culture, and as a marker of certainty in an uncertain world, in which young people frequently leave home communities for education and work, and in which their material success is severely constrained by the current state of local and global political economies. The integrated cultural framework that we employed to guide our analytical approach has contributed to our understanding of these processes as an ongoing process of cultural development and change, and to the phenomenon of non-marital fertility specifically as a product of a complex set of cultural processes. We hope our analysis will be followed by other studies that consider similarities and differences across cultural and regional contexts within one country so that we can extend these findings to other demographic processes and other parts of sub-Saharan Africa.

In this analysis, we draw on qualitative data to examine the management of non-marital fertility among young women in two rural, Black communities situated in different provinces of South Africa: KwaZulu-Natal and Mpumalanga. While the two communities share a history of economic and social disadvantage and limited access to the labour market, there are, nonetheless, distinctive features that are evident in the management of non-marital fertility. We show that young women in both communities aspire to an ideal ordering of events that places finishing education before getting married and having children but this is not easily attained. However, there are important differences in the ways young women and their families respond to union formation and childbearing that often occurs outside of a recognized union. In Hlabisa, formal processes for legitimising non-marital pregnancies through union recognition are still in place whereas, in Agincourt, more emphasis is placed on securing support and paternal recognition for the child rather than on cementing the union between the young woman and her partner. We also find that the older generation in Agincourt at times views education as a threat to marriage while this is not common in Hlabisa. Our findings have important implications for intervention programmes that often treat Black communities as homogeneous wholes.

INTRODUCTION Children in joint physical custody spend substantial periods of time in each parent's home after a parental separation. This practice has increased dramatically in Sweden during the last 20 years. In the mid-1980s about 2% of children with separated parents lived in joint physical custody, but by 2010 this figure had risen to between 30 and 40% . Because joint physical custody is more common among recently separated parents than among those who parted more than five years ago, the frequency of joint physical custody can be expected to rise even further . During the 21st century, joint physical custody has also become more frequent in countries such as Denmark, Belgium, the Netherlands and in some US states . The increase in joint physical custody has been attributed to greater gender equality in parenthood, which in turn is related to increased female participation in the labour force . Changes to Swedish family law legislation in 1998 may have contributed to increases in joint physical custody and the frequency has increased substantially in countries like Belgium and Australia following legislative changes. Greater public awareness of the importance of the father's role in children's development and social adjustment may also have contributed. Several surveys conducted in North America have shown that, in general, people now favor shared custody and joint physical custody . Earlier international studies described more favorable socioeconomic characteristics for families with joint physical custody, compared with single care parents, such as better educated fathers . Recent Swedish data show that joint physical custody is less common among families of migrant origin and those in the lowest income category , but equally common in the vast middle income category and those with high incomes . As joint physical custody is now more common, it includes families with heterogeneous backgrounds, conditions and levels of parental conflict and cooperation . Studies on children's wellbeing and mental health in relation to living arrangements need to consider the influence of other family characteristics. Factors such as parental conflict or affluence, before and after separation, affect children regardless of living arrangement . Overall, children with divorced parents face an increased risk of emotional problems, social maladjustment and low wellbeing compared to those in intact families . These risks may be attributed to the children's loss of material resources , as well as the loss of parental support, supervision and engagement . Being a mother with sole custody, or a father with no custody, is also associated with a greater risk of negative mental and physical health . Parental ill-health in turn, could impact negatively on child development and well-being . The growing body of research on the links between children's mental health and living arrangements after parental separation has shown lower risks for children in joint physical custody than children in single care arrangements . These include lower risks of fear, aggression or depression , behavioral problems and risk behaviors . One of the suggested benefits of joint physical custody is the frequent involvement of both parents which is required for developing a close and nurturing relationship. Father involvement has been shown to predict positive behavioral outcomes in children . However, research on non-residential parents and child outcomes also suggest that parental conflict could be of greater importance than frequency of contact . In a previous study that looked at all 12 and 15-year-olds in Sweden, we found that adolescents in non-nuclear families reported lower levels of wellbeing than those living in intact families and that adolescents in joint physical custody reported greater wellbeing than those living mostly, or only, with one parent . However, one restriction in this study was our inability to control for socioeconomic differences between the families. This is a limitation, because such factors have been demonstrated to be important for differences in wellbeing in children in different living arrangements. For example, in a study of life satisfaction in children from 36 countries, Bjarnason et al. found that differences between children in different living arrangements were much smaller after adjusting for socioeconomic variables. Child factors, such as age and gender, may also affect how children fare in joint physical custody. Previous studies have indicated that boys may be at increased risk for lower mental health after parental divorce while other studies indicate more negative experiences in girls, either from losing a father figure or from being in father custody . Also age differences are indicated, with early experiences of separation being more negatively related to trajectories of internalizing and externalizing problems than experience of a parental separation at a higher age . Despite this, few studies include children under the age of 10 years or they suffer from small sample sizes . This is problematic, as in Sweden this living arrangement is most frequent among six to 12-year-olds . Furthermore, the greatest debates about joint physical custody concern the youngest age groups. In our study of the total Swedish population, we found that the 15-year-olds in joint physical custody experienced more subjective wellbeing than the 12-year-olds. In contrast, we found no gender differences when it came to living arrangements or wellbeing . Our review of the existing literature shows that children's psychological symptoms and wellbeing have not been extensively studied in joint physical custody and other post separation living arrangements. In particular, studies using validated instruments and including young children are warranted. A further understanding of how parental and family factors affect children's mental health in different living arrangements is also required. This study investigated the mental health of children in joint physical custody, comparing them with children in nuclear families and in single care. It also took the family's financial situation and the parents' satisfaction with their own health, economic and social situation into account. --- METHODS A random sample of 3,200 families with children aged two to 17-yearsof-age was drawn from the Swedish Register of Total Population and these families were invited to participate in the Swedish part of the NordChild 2011 cross-sectional population survey, answering questions on their children's health and welfare. After two reminders, the response rate was 45.7% . The parent who was most familiar with the child's situation was asked to complete the questionnaire with their child. In most cases this was the mother. The child's father completed the survey in 9% of the single care families and about 20% of the joint physical custody and nuclear families. Because the primary outcome measure, the Strengths and Difficulties Questionnaire , has only been validated for children from the age of four, children younger than this were excluded and the final study population consisted of 1,297 children. --- Outcome variables The survey included the Swedish version of the Strengths and Difficulties Questionnaire , , which is designed to be completed by parents or teachers on children aged four and older. This widely used screening instrument measures psychosocial problems in children and covers both problem behaviors and competencies, including measurement of emotional symptoms, conduct problems, hyperactivity/inattention and peer relationship problems as well as prosocial behaviors. The main outcome measure in the present study was the sum of scores from the Emotional, Conduct, Hyperactivity and Peer Contact subscales respectively, which range between between 0 and 10, plus the total scores from the four subscales, which range from 0 and 40. It has been found more reliable to use and interpret the SDQ total score than to interpret the subscales separately . The Prosocial Behavior sub-scale was not included in our analysis. --- Socio-demographic variables Living arrangement was used as the main independent variable and categorised into nuclear families, joint physical custody and single care, based on the parent's answers to the survey question "with whom does the child live?" The category "joint physical custody" was constituted by those who had chosen the response alternative "the child has joint physical custody" or had stated that the child lives 180-185 days per year with the other parent. The joint parental custody and single care groups could consist of a single biological parent or a biological parent living with a new partner. The children's gender, age and household disposable income were adjusted for as potential socio-demographic confounders. The age of the children was measured in years and divided into five categories: four to six years , seven to nine years , 10 to 12 years , 13 to 15 years and 16 to 18 years due to non-linear age differences on the SDQ. Disposable income was calculated as the family's total net income after taxes, using weights provided by Statistics Sweden to adjust for families of different sizes. For the analyses, disposable income was divided into quartiles, with quartile one including the 25% with the lowest incomes. In our sample, 6.1% of the parents were born outside Sweden, including 1% in joint physical custody arrangements and 2.5% providing single care. --- Parental variables Three variables on parental life satisfaction were included as presumptive mediators: their satisfaction with their work, economy, education, leisure time and social network; their ability to influence their own, and their family's life situation; and their satisfaction with their own health. Satisfaction was measured on a five-point scale, ranging from one for very satisfied to five for very dissatisfied. Based on the results of our factor analysis, two indices were computed. Index 1 covered parental satisfaction with their economic situation and comprised the total scores from questions about satisfaction with work, economy and education . Index 2 covered parental satisfaction with their social situation and comprised the total scores from the questions about their leisure time, social network and influence over their own, and their family's situation . The question concerning the parent's health was used as a single item variable, due to the loading in the factor analysis. --- Statistical methods The SDQ total , subscale variables , parental index variables and disposable income all had higher attrition rates than the other questionnaire items. The complete-case dataset available for statistical analysis was therefore limited to 1,054 children. An iterative Markov chain Monte Carlo method for multiple imputation was used for the children with missing variables and this enabled us to include all 1,297 children in the analyses . Missing data was judged as random and equally distributed between the living arrangement groups. Socio-demographic characteristics are presented as numbers and percentages. Mean values and standard deviations were calculated for the total score and subscales of the SDQ, as well as for the parental satisfaction variables. Linear regression was used to analyse the relationship between living arrangements and SDQ outcomes in four models. Model 1 investigated the individual effect of the independent variables. Model 2 was adjusted for child gender and age. Model 3 was adjusted for child gender and age and also included family disposable income. In Model 4, the analysis was controlled for child gender, age, family disposable income and the three parental life satisfaction mediators. See Table 3 for further details of the models. Our sample size did not permit interaction analyses to study the influence of children's age on psychological symptoms in relation to living arrangements. The statistical analysis was performed using IBM SPSS Statistics 20.0 . --- RESULTS As shown in Table 1, 76.4% of the children lived in nuclear families, 10% lived in joint physical custody and 13.6% lived in single care families. Of children with joint physical custody, a larger proportion was boys than girls . More children were in the mid-age categories , compared to pre-schoolers and teenagers. Belonging to the lowest income category was more than twice as common among the two post-separation family types than the nuclear families . Mean values for the SDQ are presented in Table 2, together with mean scores for the parental satisfaction variables. There were no differences between mothers' and fathers SDQ scoring . Model 1, the unadjusted linear regression model demonstrated higher symptom load in children in joint physical custody and single care than in nuclear families. In general, boys had higher SDQ total scores than girls , but there were no differences between the age groups. Children from the lowest household income quartile showed higher symptom loads than the highest income group . Higher parental dissatisfaction with the economic situation, family situation or health were all associated with higher SDQ scores in the unadjusted model. Adjusting for the confounders of child gender and age and child gender, age and household income , did not change the different patterns of SDQ scores in relation to living arrangements. When adjusting for the parental life satisfaction variables as mediators , the coefficients decreased from 1.4 to 1.1 for the joint physical custody group from 2.2 to 1.3 for the single care group. wellbeing and life satisfaction may be important factors when it comes to explaining why children's mental health varies in relation to different living arrangements. Children's gender, age and family household income only made a marginal contribution to explaining the differences in the children's mental health, while parental satisfaction with the three aspects of life had more impact. Despite the increased practice of joint physical custody, the results show that parental economic and social factors still differ substantially between parents in different living arrangements. Like many previous studies, this research shows that children with separated parents tend to have higher rates of mental health problems compared to children in nuclear families. We may speculate that the increased risk of emotional or adjustment problems in children with separated parents, compared to those living in nuclear families is related to the actual experience of family break up. Some previous research has indicated that differences in children's mental health and problem behavior occur before parental divorce, suggesting that this could be a symptom of family dysfunction or part of a problem that results in parental separation , rather than a consequence of their living arrangement. We can also hypothesise that the life satisfaction of separated parents is, to a certain extent, determined by pre-separation factors associated with the relationship with the former partner. In our study, as reported in previous research, the risk of mental health problems in children in joint physical custody was lower than for children in single care. Positive relationships with their parents are important for children's wellbeing and mental health and, according to previous research, children in joint physical custody report more satisfaction with their parental relationships, in particular with their fathers, than children in single care . In fact, Swedish data show that children in joint physical custody are as satisfied as children in nuclear families with their parental relationships . Children living with their parents seem to have stronger relationships with them and this may contribute to better mental health in children in joint physical custody arrangements. Parents who have low levels of contact with their children, mostly fathers, are more dissatisfied with their lives and are reported to suffer from poorer health than other parents . It is possible that parents who have joint physical custody, and share responsibility for their child with the other parent, have happier lives and are more likely to engage with their child and form secure relationships, helping to ensure that their child's mental health is good. --- Methodological issues The cross-sectional design of this study does not allow for any firm conclusions about causality. Longitudinal studies with parental and child variables before and after the parental separation are needed to study effects on post-separation living arrangements on child mental health. Until such studies are available, however, we have to make the best out of cross-sectional studies like this one, where the rich data about parental life satisfaction is a particular strength. There were no indications of a selective attrition in this study. A non-responder analysis showed no significant differences in the distribution of background variables among responders and non-responders, with the exception of country of birth, where the proportion of foreign-born parents were 6.1% and 8.1%, respectively. However, the proportion of children in joint physical custody in our study was comparable to other recent Swedish studies. Possible socioeconomic factors may account for differences in children's psychological symptoms between living arrangements. To adjust for this, we included family household income. We choose not to include parent's educational level, because this is associated with income and there was a high non-response rate for father's educational level. Families of migrant origin are less likely to have joint physical custody in Sweden , but the number of foreign-born parents with this living arrangement was too small in our study to allow us to control for this variable. We included parental satisfaction with their economic as well as social situation together with a single item rating parental satisfaction with own health. The indices on satisfaction with social and economic situations were associated with living arrangement in the final model but not satisfaction with health. Potentially, stronger mediating effects would be observed with a more comprehensive health measure, comprising also psychological aspects. Despite controlling for household income and parental satisfaction with various aspects of their life situation, we cannot exclude the possibility of selection effects that nuclear families, joint physical custody and single care differ in ways that we have not been able to control for in this study. In this respect, parental engagement in their children and inter parental conflict would be of particular interest. The instructions for filling out the questionnaires were directed to parents and the parent was advised to fill out together with the child, if appropriate. However, we could assume that most scorings were made solely by parents. This could be a drawback since parents with higher mental ill-health might judge the child as being problematic. However, the results from our study are in accordance with several previous studies of mental health and living arrangements, where school children themselves have answered questionnaires. . We had the opportunity to include children from four to 18years-of-age in our sample. This broad age range is a positive advantage, because children's age may influence how they fare in different living arrangements . However, the inclusion of pre-schoolers, mid-age children and teenagers, is also an important limitation, because although our outcome and exposure vary by age, our sample was too small to permit interaction analyses of the different age groups. This means that our general results cannot be applied to specific age groups. Joint physical custody is a more frequent living arrangement in Sweden than in most other countries and the findings may not apply to other countries, as children's wellbeing and mental health are influenced by the society they live in as well as family factors . These include the stigma associated with parental separation and post separation agreements. However, when they compared child outcomes in different countries, Bjarnason et al. found that, overall, children in Nordic countries reported higher life satisfaction than children in countries with less developed social security systems, but that the diversity between children in different living arrangements were similar. It is possible that a child's mental health may affect their parents' decisions about custody and residency arrangements after a separation and that children's ill health may also affects the parents' wellbeing . In addition, parents with mental health or socioeconomic problems are more likely to experience conflict when it comes to their child's custody and living arrangements . This calls for longitudinal studies into living arrangements and child mental health, so that these issues can be clarified and the causal directions in these associations clarified. Parental life satisfaction, as well as age at separation and the duration of the separation, should be investigated further as these may help to explain the differences in symptom loads between children in various forms of living arrangements. In conclusion, this study shows that children in joint physical custody have better mental health than children in single care, but not as good as children in nuclear families. These results confirm that findings from earlier studies on adolescents also can be extended to younger children. Children's mental health in different living arrangements is associated with parent's life satisfaction. The clinical implications are that empirical data on children's mental health in different living arrangements are important for counsellors and mediators for separating parents. Not only for adolescents, but also for younger children, access to both parents in their everyday lives seems beneficent for children's mental health. --- DISCUSSION In this cross-sectional study of 1,297 children aged from four to 18 we found that the children's mental health in different living arrangements was associated with parental satisfaction with their health, social and economic situation. In accordance with previous research, children in joint physical custody had a higher symptom load than children in nuclear families. The children in joint physical custody had an intermediate position in terms of the SDQ emotional, conduct, hyperactivity and peer contact problem measures, with children in nuclear families having the lower symptom load and those in single care having the highest. The parent's satisfaction with their health, social and economic situation followed the same pattern. Parents with sole responsibility for their child's care were the least satisfied and those in nuclear families were the most satisfied. There were only small differences in the beta-estimates of the SDQ scores between the children in single care and joint physical custody when the analysis was adjusted for the three dimensions of parental life satisfaction. This finding suggests that parental

This study compared the psychological symptoms of 129 children in joint physical custody with children in single care and nuclear families, using a nationally representative 2011 survey of 1,297 Swedish children aged between four and 18 years. The outcome measure was the Strengths and Difficulties Questionnaire (SDQ) and its association with three dimensions of parental life satisfaction was investigated. Linear regression analyses showed higher SDQ-scores for children in joint physical custody (B = 1.4, p < 0.001) and single care (B = 2.2, p < 0.001) than in nuclear families, after adjustment for socio-demographic variables. The estimates decreased to 1.1 and 1.3, respectively, after being adjusted for parental life satisfaction ( p < 0.01). Our findings confirm previous research that showed lower symptom scores for children in nuclear families than children in single care and joint physical custody. Parental life satisfaction should be investigated further as a possible explanation of differences in symptom load between children in different living arrangements.

Introduction While cars possess symbolic and affective meanings that vary by demographic group , car aficionados tend to "emphasize masculine powers and exclude women" . These so-called "car guys" also known as gearheads, motorheads, and car fanatics, own muscle and sports cars. They take great pride in their cars and socialize with others sharing similar traditional values. Central to their identity is taking their putative rightful position in the "driver's seat, " a role perpetuated by "ambivalent sexism" and the stereotype that men are superior to women as drivers . Ambivalent sexism recognizes nuances of sexism by taking into account both beliefs that women are inferior and beliefs that they belong in Dundes . /fsoc. . traditional roles . This typology has relevance to a driver's gender in driving scenarios: Skinner et al. examined the relevance of ambivalent sexism to accident scenarios in which a defendant was depicted as navigating congested traffic. In this scenario, research participants who held hostile sexist attitudes assigned greater culpability to women compared to men. In another scenario that involved icy roads, participants high on benevolent sexism were more likely to deem a woman responsible for the accident than a man facing the same conditions. This study exemplifies the potential empirical importance of understanding how sexism interconnects with conceptions of driving. Group identity is also fundamental to understanding hegemonic masculinity in car guys. According to social identity theory, attitudes and behaviors are commonly based on group memberships . In the car guy subculture, hegemony reinforced by group identity provides a bulwark against identity threats, specifically challenges to masculinity. Even men outside of the car guy subculture tend to view interest in cars as a masculine credential. For example, Fisher found that when male nurses took care of male patients, that is, when they were being judged by other men, they enacted "culturally dominant masculinity... [talking] about blokey things [like] surfing and cars" including building hot rods . This allowed them to assert their heterosexuality in a field in which they are in the minority. For car guys invested in car culture, however, passing references to cars are insufficient to bolster masculinity; instead, they emulate and identify with other car guys who saliently express their devotion to fast, high-performance cars . Their presentation of self is broadcast via their cars and driving styles as well as social media, providing outsiders with an opportunity to gain insights into their subculture of performative masculinity. --- Memes as data This semiotic analysis involved decoding memes by interpreting salient expressive data of car guys. Memes as a window to social phenomena add to other forms of social media that provide new insights into the psychosocial aspects of groups . They are a participatory and creative reproduction of intertextual and remixed content, commonly disseminated on social media forums including Facebook, Twitter, Tumblr, YouTube, Reddit, and 4chan, among others, and a form of data that is "deeply entwined in the fabric of social life and discourse" . Memes provide insight into the values of those creating and consuming the qualitative content that is ripe for semiotic analysis [refer to Cannizzaro and Mahasneh and Bashayreh for contemporary applications of semiotics to memes]. --- Study aims This study leverages car culture's conspicuousness through memes in order to consider the following questions: What attracts men to car culture? How is a car conflated with a car guy's sense of self? and How are these phenomena relevant to patriarchy? Despite limitations in analyzing car guy memes to suss out answers to these questions, this methodology provides an unobtrusive means to assess the subculture using data purposely shared in the public domain. --- Methods Memes were selected from the yields of search engine queries using the keywords "Car guy memes" + images in November 2021 in the three most popular US search engines: Google, Bing, and Yahoo . These images, in turn, had been drawn from a variety of sources such as MemeGenerator , Quickmeme , and We Know Memes . Other sources yielded in search engine queries were https:// awwmemes.com, https://www.memesmonkey.com, https:// me.me/, https://ballmemes.com/, https://www.memecenter. com/, https://knowyourmeme.com/, https://carhumor.net/, and Pinterest. One of the most common sources of memes that appeared in search engine results is Car Throttle. Started in 2009 for young, millennial car enthusiasts, it claims to be the world's largest cross-platform automotive publisher, drawing from Facebook, Instagram, YouTube, and Snapchat with a monthly audience of 400 million people and a core demographic of males aged 18-34 . Memes expressing general subcultural values that revealed parameters of masculinity and those pertaining to car guys' view of women and/or dating were selected for analysis as long as the memes appeared in multiple but varied formats, a process that yielded 60 different memes, which are analyzed in this paper. For example, car memes dealing with brand loyalties were largely excluded as were memes related just to spending great sums on cars . Similarly, many memes were out of scope as they were simply about how others do not share the same knowledge of or interest in cars, e.g., "Check engine"/Yup, it's still there [guy looks under the hood] or "How it feels when you talk to non-car guys about car specs" [guy in a restaurant booth staring ahead with a table pushed up against a blank wall]. Memes selected for the study were then analyzed for recurring salient themes, specifically themes that emerged from the data rather than pre-existing themes. The selected memes were then interpreted within the context of relevant literature. The following themes that emerged are examined in this paper: vehicles with a masculine persona, cars as a human body, car-human rear end equivalency, car-human rear end sound equivalency, performance as male power, women as symbolically Dundes . /fsoc. . equivalent to cars, memes in which a woman is valued less than a car, car guys in relationships with women, cars as a substitute for women, and car-women comparisons with cars as an implied sexual substitute. The memes analyzed in this paper reflect dramaturgical masculinity, offering a contemporary means for "car guys" to succinctly "encode themselves... into the digitally mediated content they create, circulate, and transform" . In addition, using memes as an investigative tool can enhance our understanding of a subculture that has been largely neglected in the academic literature, with treatment that is "scant at best" . --- Car culture described Car culture revolves around a passion for cars, namely fast cars. Car guys tend to spend extensive time and money on their vehicles as a labor of love. Norms commonly include modifying or customizing cars, keeping them clean and free of scratches and dents, relishing and enhancing various features of their cars , and admiring other standout cars. "Making their vehicle stand out from the rest" is a key aspiration of car guys. This description jibes with a video describing car guys by a car reviewer and self-professed car guy, Gold Pony , whose YouTube channel videos boast over 60 million views . Gold Pony calls reviewing cars an "addiction, " not just a hobby, consistent with a subculture known for an obsessive interest in cars . Car guys gravitate to muscle and sports cars, terms that are sometimes used interchangeably, despite differences between the two types of cars. Muscle cars, e.g., certain Camaros, Challengers, Chargers, Corvettes, Mustangs, and Gran Turismo Omologatos have an engine that is at least a V8, an eight-cylinder piston engine with more "muscle" than cars with four or six cylinders for fuel intake. These American-made twodoor sports coupes have powerful engines designed for highperformance driving and are associated with patriotism . Sports cars, such as particular models of Porsche, Ferrari, Lotus, or Lamborghini cars, tend to have recognizable sleek body styles, with elements reminiscent of race cars. They are smaller and lighter than muscle cars, winning them notice for acceleration, speed, and performance . Admiration of these vehicles builds camaraderie among car guys but also conveys that insider status depends on authenticity, namely values, attitudes, and behavior that are "real" or genuine, as a common meme reflects: "Real car guys respect other car Some car guys believe the Camaro, Barracuda, Challenger, and Firebird are pony cars, not muscle cars, based on the first Ford Mustang ( ), a classic pony car . guys" although several variations exist that add an insideroutsider proviso by adding the words, "Except Honda. Nobody likes them". --- Car culture in societal context There are several reasons why car symbolism has greater resonance for men than women. Historically, a woman's place was as a homemaker and a housewife, with driving presumed to pose a temptation to shirk domestic responsibilities . Discouraging women from considering cars to be part of their domain served to inculcate traditional gender roles and encourage their dependence on men . In turn, men's governance of car matters became conflated with their sense of autonomy and control that stymied women's physical and metaphorical mobility. The expression "where the rubber meets the road" affirms how driving connotes power, which for male drivers, cements their status as paterfamilias. It would be remiss to omit the obvious aspects of car culture that are associated with masculinity such as the "exhilaration of driving at high speed, the great pleasure in out-accelerating a rival vehicle when the traffic lights turn to green, of overtaking "every vehicle on the road, " and of having a beautiful girl sitting alongside in the front passenger seat" . The term "passenger princess" refers to a car guy having an attractive woman in the passenger seat as a type of ornamental accouterment, with her function understood to be to a foil to the driver's dominance. Gendered aspects of car culture are also notable in motor contests that resemble updated chariot races , events where women drivers threaten the macho image of the sport . This applies to various maledominated professional races, such as National Association for Stock Car Auto Racing , with stock cars that are ordinary cars modified for racing, as well as Formula 1, race cars with a single seat. Women like Janet Guthrie, who in 1976 became the first woman to take part in a NASCAR Winston Cup Superspeedway Race, had trouble finding sponsorship due to exclusion from the old boys' network. About 25 years later, professional racer Danica Patrick gained more traction but was also acclaimed for her pin-up posters and the 2008 Sports Illustrated bikini shots in which she "unapologetically used sex appeal to promote herself " . Embracing stereotypical femininity included breast implants, "during her second full-time year in the NASCAR Cup Series, at age 32 to "have the whole package, "" . Thus, Patrick's inability to project hypermasculinity led to her deference to the sport's embodiment of traditional gender roles in which part of "the package" for a woman entails catering to the male gaze. --- How vehicles inculcate a masculine persona Other manifestations of cars' ability to confer masculinity appear in the lucrative Fast and Furious film franchise as well as the video game Grand Theft Auto , in which masculinity is defined by both sexual prowess and displays of aggression . In the case of the former, the word "fast" is slang for sexual promiscuity while the word "furious" can mean "violent or intense." Similarly, GTA relies on female characters that tend to be sexualized and subordinate to male protagonists, reinforcing traditional gender stereotypes . In addition, Hollywood reinforces the nexus between cars and male power by linking being without a car and abstinence in males, e.g., in The 40-Year-Old Virgin in which actor Steve Carell plays the title character who commutes on his bicycle . In the popular Disney-Pixar Cars franchise, with anthropomorphized talking cars, the star is a Corvetteinspired car, Lightning McQueen. McQueen is a nod to Steve McQueen, star of the 1968 film Bullitt, who drove a muscle car, a Ford Mustang GT, renowned for its use in a famous car chase scene on the streets of San Francisco. Furthermore, car chases and other types of competitive driving are de rigueur in many action-adventure movies . This theme also pertains to the iconic, fictional, and animated Speed Racer of the mid-1960s, whose Mach 5's front end is patently phallic, with its prominent rocket-shaped central protuberance. Although Speed Racer's car exists in the fantasy realm of animation, vehicles' sexually suggestive imagery may at times be less symbolic and more overt in terms of their representation of a man's body: "Truck nuts are fake testicles that hang down from the back bumper of a truck, usually from The car used in the film is a trophy of sorts, that sold for $ . million in . In fact, McQueen, had unsuccessfully tried to buy the car , revealing its symbolic importance. the hitch... In the mid-to-late 2000s, the product hit a tipping point and truck nuts exploded [in popularity]" . One of the most blatantly sexual parts of muscle and sports cars is the manual stick shift, "a metaphor for a man's phallus" . For example, movie car chase scenes usually include various camera angles that show a man with his hand on the gear shift, indicating the driver's finesse in controlling his stick, without relying on automatic gear shifting that takes control away from the driver. Interestingly, the word "drive" in noun form is an innate, biologically-determined urge to attain a goal or satisfy a need. The following meme expresses that automatic cars are not "real" cars, presumably because they have lost their masculinity without the power conferred by the stick shift. Refer to Figure 1: Real cars do not shift themselves. This meme is a riff on the well-known book by humorist Bruce Feirstein, Real Men Don't Eat Quiche , which satirizes stereotypes of masculinity. Cars without stick shifts could be seen as symbolically castrated since once such a car is in "drive, " no manipulation of the gear lever is needed, resulting in a loss of phallic control and a blow to masculinity. Another meme treats the stick shift not only as increasingly rare but as a living being. --- Endangered species [picture of a gear shift grid] A manual transmission requires the use of a clutch, a pedal used to connect and disconnect a vehicle's engine from its transmission, a word associated with stereotypical masculinity. Being a "clutch player" means to perform well at an important, high-pressure moment, based on the idea that a clutch facilitates control over a situation . Furthermore, muscle cars are arguably factory-made hot rods . A rod is "a time-honored phallic symbol" while the term "hot" is associated with sexual readiness and attractiveness. This meaning was blatantly apparent in the 1971 "Dickmobile" hot rod on the cover of rock band Steppenwolf 's "Ladies Only" album. Similarly, revving an engine to warm it up incorporates revving, with a metaphorical meaning to excite a person , complete with sound effects. Burnouts "Odd Rod" trading cards of the s feature various hot rods and muscle cars with menacing drivers (like Speed Demon, Ram Charger, King Cougar and Big Daddy). One of the few women drivers is Drag-on-Lady, a play on the term dragon lady, a domineering woman. She is portrayed with a phallic, witchlike nose and chin, gripping a ball connected to a stick shift, that is, a castrating old witch appropriating hegemonic power. Frontiers in Sociology frontiersin.org --- FIGURE Real cars. Photo credits for meme: photo by Dicson @smartdicson, https://unsplash.com/license; https://unsplash. com/photos/ o h mRLI-. are arguably a form of "visual special effects" denoting heat that signifies how a driver is literally and metaphorically "smoking, " slang for sexually attractive. These associations begin early, as with the brand "Hot" Wheels, toy cars marketed to boys . More overt symbolism exists related to modifying a hot rod to boost its torque using a stroker kit . Suck, squeeze, bang, blow is a double entendre referencing the internal combustion engine cycle completed in four piston strokes , with symbolic meaning captured in a meme: Suck, squeeze, bang, and blow [Sudden Clarity Clarence template with guy looking confused] And it's not a porno movie --- Cars as a human body While cars can connote masculinity due to one part or in their totality, there is also support for cars as extensions of humans by virtue of various car parts having equivalents in the human body, as the term "muscle car" suggests. Cars as "cathected, humanized machines" undergo repairs at "body" shops. In this sense, the polysemic nature of cars means that they may not only connote phallic power but also may represent a human body, including a surrogate woman. In other words, the gender-related symbolism of the car varies according to context . "Head" lights imply that the front of the car is a head, while head "lights" function as eyes . The front-end car grill for ventilation functions like a mouth just as a grill on a person can signify teeth ornamentation. In fact, one blogger wryly notes that "There's an entire corner of the auto accessory industry built around the realization that the front of a car looks like a face. People who never quite get beyond that realization seem to do mainly two things with that information: Buy tickets to every movie in Pixar's "Cars" franchise and put "carlashes" on their vehicle" . Similarly, a Fiat Canada ad makes use of how car headlights and grills resemble faces . This phenomenon also appears in memes: The hood, called a bonnet , also connotes that the front end of a car is a head. A hood is a head and neck covering while in Scotland, a bonnet can mean a cap for men or boys while a bonnet is a type of military headdress worn in Scottish Highland infantry regiments. Similarly, consistent with a car as an ersatz human body, tires, the means for locomotion, would be symbolic feet, consistent with a "flat tire, " slang for when a person steps on the back of another person's shoes. Big Foot tires are specialized, oversized tires sold to the military and civilians alike belief that shoe size correlates with penile Expressions applied to humans "to run out of gas," "blow a gasket" or "get a tune up" provide linguistic support for perceptions of cars as pseudo-living beings. The term "muscle car," also connotes a human body, a term first used in to refer to "an American-made two-door sports car with a powerful engine" . Car Lashes to decorate a car's headlights with fake lashes make the car's "eyes" more prominent, a product targeting women: "Since exploding online in , CarLashes ® have gone from a girly trend to a diva necessity" . Frontiers in Sociology frontiersin.org Dundes . /fsoc. . length). This could also explain why a wheel clamp or wheel lock is commonly called a boot, with cars violating parking rules being "booted". --- Car-human rear end equivalency The rear end of the car has "tail" lights and a "tail" pipe for exhaust gas. Tail is slang for buttocks and one meaning of a trunk is posterior, as in the expression "junk in the trunk, " slang for fat in the buttocks . Various memes treat a car's rear end as belonging to a human, e.g., in the case of tailgating: Oh, you want to ride my ass? [template of Gene Wilder as "Condescending [Willy] Wonka"] Please tell me how that will make the car in front of me drive faster --- Car-human rear end sound equivalency The desire to make the conspicuous "rumble" of a car's exhaust even louder unconsciously replicates sounds of human bodily functions, specifically with the tail pipe emitting a sound comparable to passing gas. In animals, the tail is located near the rear end, making the fumes from the tail pipe positionally analogous to mimicked human flatulence, an act and sound that is more acceptable among males . Flatulence has also commonly been compared to the power of thunder, from Aristophanes' Clouds and Chaucer's Miller's Tale to a movie about a boy with uncontrollable flatulence called Thunderpants ; it may be related to the naming of the Thunderbird muscle car as well. Passing gas also has latent meaning as a form of anal power, as with bullroarers, an instrument used in a range of different cultures, exclusively by men, to produce the sound of flatulence . Thus, the volume of ersatz The term boot refers to a trunk in the UK, reflecting polysemic meaning. However if the front end of a car is a head, then the rear end of the car may not always be a rear-end equivalent, but rather symbolize a foot . President John F. Kennedy "had a 'thing' for cars. Like most red-blooded American males, he appreciated big, shiny, powerful automobiles," reflected in his Corinthian white Ford Thunderbird convertible . Shininess, like knights in shining armor, is achieved by car waxing that links car's phallic power to sexual readiness , a common goal of car "bu s". In Australian band Midnight Oil's song "Bullroarer," a children's version of a bullroarer was used . The band respected the bullroarer as a "sacred instrument" making sounds "only initiated men are supposed to hear" . flatulence discharged by men in their cars brings welcome attention to car guys, but it is not a sound that women produce or mimic to gain stature. The role of exhaust in attracting notice is the subject of memes. I do not always just sit and listen to my exhaust But when I do, so does the whole neighborhood [rear end of muscle car] The rumble is reminiscent of race cars and commonly marketed to men in ads that cater to the "male fantasy of being a race car driver, the ultimate symbol of combustion masculinity" . Allowing drivers to make their cars louder is a marketing gimmick that plays on conceptions of masculinity: "With the push of a button, the soundtrack is mechanically enhanced to give the car more of a V8 exhaust growl [while] the throaty rumble enhances in sport mode" . This concept aligns with a description by an online car-buying service: "Enhancing the sound of your exhaust gives a different, but equally satisfying, sense that the vehicle you are driving is a force to be reckoned with" . While loud cars may have broad appeal to men, they are especially appealing to car guys. Various memes celebrate their pride in making sure they are heard, as well as their willingness to flout noise regulations and even pay fines for the privilege of announcing their presence. In fact, disdaining the authority of their archrival, the police , is a value-added bonus to gaining notice, as the meme below conveys. --- I know it is loud. Write the ticket [template of actor Leonardo DiCaprio throwing money] Similarly, another car noise, honking a horn, can bolster masculinity. Hitting or blasting the horn conveys aggression, like the horn of an animal that poses a threat. Not coincidentally, the word horny has a sexual meaning, showing that horns conflate sex and aggression. --- Performance as male power Combustion masculinity that entails auditory signaling is closely linked to car "performance" and sexual prowess featured in car ads . This assertion can be confirmed by a simple web search using the words "male performance" that will yield pages of websites related to erectile dysfunction. The emphasis on 0-60 in X seconds can be decoded as the ability of a man to be in a state of readiness in mere seconds, banishing fears of a metaphorical, and public, display of symbolic impotence. The designation 0-60 is called "pick up, " referring to both how fast a car accelerates and starting a conversation with someone with the goal of having sex. Although this measurement of acceleration is a major selling point, certain 0-60 claims actually require a specially-prepared drag surface or are simply misrepresented. Car marketing capitalizes on these male performance fears and desires, suggesting how driving certain cars embodies masculine ideals, separating men from boys and men from women in a way that is purposefully exclusive, as Avery describes: His Porsche becomes a magical transport, bringing him back into the game and enabling him to capture the attention of women... [since].... only "real men" can handle the car . --- Women as symbolically equivalent to cars While cars provide a means to exhibit the qualities of a "real man, " whether women can fulfill the same need is more complicated: they may either enhance virility or undermine male dominance. Men in romantic relationships must engage in "give and take, " a reality of relationships that ipso facto gives women power. Thus, a man's reliance on a woman for fulfillment makes him dependent on her, a quality at odds with hegemonic masculinity. However, if cars can substitute for women as needed, then men have a backup plan that protects them in the event that a woman undermines their authority, as suggested by the meme, "Men love women, but even more than that, men love cars." Better yet, as a pre-emptive strike, car guys may unconsciously promulgate the notion of cars as superior to women on social media and elsewhere, treating sports and muscle cars as an acceptable fallback if a woman threatens their dominance. Support for this interpretation lies in "sports car as girlfriend" memes. In the example below, the equivalency is based on the financial drain imposed by both a girlfriend and a sports car: ) with lyrics describing how a man told his girl he'd "have to forget her" given his preference for his car that does not "talk back". A similar meme has the same equivalency theme, but escalates the sexism: Having a turbo car is like having an Obsessive girlfriend [overly attached girlfriend template] High maintenance costs And always needs attention In the above meme, women are again compared to cars, but this time referencing their allegedly excessive emotional needs. Furthermore, the meme also implies that women who need a lot of attention are "obsessive" . Women's desire for attention may contrast unfavorably with their traditional role as nurturers who meet but do not make demands. In another car-woman equivalency meme, a man defines a partner's love as passively accepting her status as equal to her partner's prized possession: I just want a woman who's nice enough that I actually Couldn't choose between her and my car, but who loves Me enough to never ask me to Another meme points out how men and women think differently when it comes to cars: Her: He's probably thinking about other girls [picture of a couple in bed: a woman looks over at the man with his back to her as he stares ahead pensively] Him: Are mechanics just doctors to cars? The above meme compares women who are inclined to spend time thinking about such matters as relationships, fidelity, and attractiveness to car guys who are preoccupied with their car and its welfare rather than their significant other. Another popular meme has a similar message: Girls are like "All guys think about is sex" [red sports car] Bitch please Similarly, in the video of Rihanna's Shut Up and Drive , Rihanna is virtually ignored by the two men who are concerned only with winning the imminent drag race. Despite her chorus chant to "shut up and drive" combined with suggestive gyrations, her invitation for sexual intimacy is ignored while the two men featured are solely concerned with winning the race, with their hands shown on their stick shifts. In other words, the word "drive" means sex to a woman while for men the word can entail competition with other men, prioritized as a means to establish the pecking order in a hierarchy of masculinity. /fsoc. . --- Memes in which a woman is valued less than a car The next memes acknowledge women as desirable, but still as -less-desirable than a flashy car: If you had the choice of your dream girl or your dream car [red sports car] What rims would you put on it? Women may also be treated as an expendable commodity that is inferior to a car: Why no girlfriend? [sports car] Because he has a bitchin' race car!!! This meme also includes thinly veiled misogyny, suggesting that a bitchin' car is better than a bitchin' woman, an interpretation based on how the word bitchin' is slang for either remarkably bad -or-good, depending on context . In the subsequent meme, women's #7 ranking shows their placement as patently subordinate to cars, exacerbated by the expectation that a woman should love cars, in accordance with a car guy's interests. The more I learn about relationships... [sports car] The more I love cars While this meme does not specifically articulate that cars are preferable to women, it hints at this eventual conclusion based on problems with relationships. When considered in conjunction with the next meme, it seems likely that fraught power dynamics common in relationships explain the preference for cars, specifically playing on the stereotype of women as mysterious, unpredictable, and hard to manage. I love cars more than women When a car has a problem, the mechanic sorts it out But when a woman has a problem, you wouldn't know until it's too late The next meme conveys a preference for cars, but instead of blaming relationship difficulties, it implies that driving the car satisfies a man's sexual needs. --- I love my car more than my girlfriend [picture of a screw blower] It has a big blower Blower terminology is loaded with sexual innuendo. A screw blower is a supercharger that brings maximal air into the motor to increase combustion output using a screw compression element, comprised of male and female rotors to boost engine power . Superchargers feed into inflating a driver's stature: "Fast cars and even pretty cars are all about horsepower. One of the best ways to get there is with a supercharger. There's no better way to draw a crowd around your car than with a blower sticking through the hood" . These modified cars, sometimes with a big block engine mounted in the middle, connote a sense that the engine is too big and powerful to contain. When car guys do reference their sex life, a lack of emotional commitment to women emerges as a theme. The following meme that references mechanical expertise likens sex to working on cars while at the same time conveys disrespect for sexual partners: --- I screw I nut I bolt It's tough being a mechanic [Two kinds of screws and a nut] Screw is a slang verb for having sex while nut as a verb is slang for ejaculation. Anatomically, bolts have a head, and a nut is screwed onto the threads at the bottom, which could explain the expression "nuts and bolts" meaning "essential, " that is, if the two items are the symbolic equivalents of a penis and testicles, that would be prized in patriarchy. The line, "It's tough being a mechanic" is sarcasm given how the meme's "hit it and quit it" description of casual sex is blatant sexism that glorifies men's avoidance Dundes . /fsoc. . of commitment and commodifies women as a means of sexual gratification. --- Car guys in relationships with women The previous memes apply to men who are not in committed relationships. However, car culture memes also reflect concerns of car guys with partners. The memes below reiterate the wish that women could understand car guys' devotion to cars and presumably their preference for spending money on activities such as car customization rather than on a wife or family. They said the GTR was not a family car... [guy loading groceries into the back of red sports car] So I got rid of my family Interestingly, the next meme acknowledges women's power, as conveyed by the word "let" : Behind every great driver Is an even greater wife who lets him buy car parts However, the man in the above meme is identified as a "great driver" while the wife's "greatness" is not only passive but also defined as deferring to her husband's wishes, consistent with the definition of hegemonic masculinity in which women become inured to "accommodating the interests and desires of men" . This pseudo-praise of an "even greater wife" is a form of ambivalent sexism with its ostensibly positive tone that in actuality requires a wife to accede power in spending-related decisions . The following meme also relates to a couple's spending, but involves circumventing spousal input: Quick! Gotta make it look dirty [guy working on a car engine] Before the wife notices it's new! The term "the wife" depersonalizes a man's spouse and implies her conformity to a traditional role. It also suggests that wives: should be deceived, can be deceived by only a simple ploy, and that they are an obstacle to men enjoying a favorite pastime. The number of other expressions that treat women as sex objects speaks to the pervasiveness of this mindset: "smash and dash," "F$% * and chuck," "copulate and depopulate," "tap it and gap it," "screw and scram," "pound and bound," "hump/pump and dump," "toot it and boot it," "conceive and leave," "bust a load and hit the road." The last example is particularly relevant to cars' association with freedom from commitment. Memes can also convey car guys' love of cars, chosen over amorous activity: [Woman]: Babe, it's raining out. Let's rent a movie and cuddle [Woman lies on a bed in lingerie, holding a remote control] Never got the movie [Sports car driving through the flooded parking lot, creating a big spray of water in its wake] The following five memes reflect how car guys' love of cars can escalate into a desire for multiple cars that demarcates men from women: Why do you need more than one car?? --- OCD Obsessive car disorder An ethnography of car culture revealed that a man with a "car obsession" sometimes justified the resources he expended on excessive cars by "discovering" an appropriate vehicle for his wife's use , co-opting her into his hobby that was at times obsessional. Expenses for some may even include "car condos, " car storage units marketed to men "who sometimes struggle to persuade spouses of the wisdom of plunking down $300,000 for a garage" , a type of "lavish retirement home for their cherished vehicles" . Even women that condone or support cars guys' predilections may be reminded of their status relative to their husband's preferred car: If he lets you drive his car [woman sitting behind the wheel of a car] You better feel damn special Notably, the above meme starts with the word "if, " implying that a woman may or may not be permitted to drive a spouse's beloved vehicle. In fact, even "'girl racers" feel compelled to tolerate "compliance with the subordination of women... to accommodate the interests and desires of men" . In an extreme display of woman vs. car, women that cannot understand this car fixation are expendable: When she says that she doesn't like the car [picture of sports car] The sad time has come where You must part with the girl The woman is also called a "girl" above, a way to demean a woman who does not support her partner's avid interest in cars. --- Cars as a substitute for women Car guys' love of cars may also be escalated to the point where a car is portrayed as a surrogate romantic interest: The rings she wants [2 overlapping wedding bands] The rings I want [four round illuminated taillights] Related memes liken a man's feelings about his car to "popping the question" : If you like it, then you need to put a ring on it [Picture of a car's o-ring used for gaps in a gland's mating hardware] Note: a gland is a sleeve used to seal a piston rod or other shaft. [Man bent on one knee, facing a red sports car, extending a wheel rim toward the car] ... She said Yes! Proposing, whether to a woman or a car, implies possession and ownership that enhance virility . Once a car guy ties the knot, his car may still be a priority, as the meme below indicates by the groom using the treasured wedding gown train to clean his tires : Car guy priorities [Bride stands next to a car as groom bends down to use her wedding gown train to polish his wheel rims] Various other memes have a "no explanation necessary" approach to a car substituting for a woman: Not only do cars also apparently offer the advantage of escaping women's alleged mood swings and histrionics, but they also allow men to avoid women altogether and still project masculinity, as the next meme implies: In contrast, the problems cars pose do not jeopardize the man's self-esteem: When you love your girl, But she has [sports car at the gas pump, with the gas nozzle in the tank] Drinking problems When women are not so manageable, cars apparently present a viable option as a replacement, as in the meme above that refers to a fairlady . Refer to Figure 2: Trade her for a fair lady. Car-women comparisons with cars as an implied sexual substitute While significant others in car culture require special handling, memes can also express a "hostile" form of sexism, essentially misogyny, in which women are compared to cars as commodified sex objects . Here we see one of the most beautiful things on earth [Woman in a leotard and high heels leaning suggestively into the window of a sports car Her face, seemingly irrelevant, is not visible] The other wears high heels The next meme provides context for the previous memes, explaining why car guys portray women as expendable commodities, useful for sexual gratification: Only gives you pleasure when she wants [young woman] Gives you pleasure when the boost kicks in [sports car] The meme above clearly decries women's ability to withhold sex, a right relevant to the #MeToo and Yes Means Yes movements. In contrast, cars offer no resistance or threat to male dominance; they only enhance it. This leads to car substitutes as a way to avoid rejection, maintain control, and enhance virility. While cars can substitute for women in projecting masculinity, women are still necessary for their role in procreation. However, there is some meme evidence that fantasy "conceptions" of cars include wishful thinking in how this reproductive role might become obsolete. [Mercedes trunk opens and the front of another miniaturized Mercedes emerges from the trunk] Taking this point a step further, if it is cars and not women that make men happy, and women are difficult, demanding, and fickle individuals who also abuse their power as sexual gatekeepers, then the right kind of car is more desirable. See Figure 3: Please wishing well... This meme arguably pits the woman against the car, as a competitor of sorts. In addition, the woman is shown as naïve to what men really want and incapable of becoming more alluring than a fast car even with the help of magical powers. The words "impossible to resist" are consistent with an inexorable car obsession in which needs and wants along with aggression and libido have free reign. The car transmogrifies into a mistress of sorts, which car guys may modify to be "pimped out" or "tricked out, " perhaps unconscious references to prostitutes who offer sexual gratification without commitment or judgment. This could also relate to the perception that when men marry, they are "settling down, " giving up the "high octane" excitement of going into "overdrive" and living life "in the fast lane" to accede to expectations of "the wife" or mundane responsibilities associated with a committed relationship in which they are "spinning their wheels". --- Discussion Despite the advantages of memes as an unfiltered data source, a major limitation is an inability to identify the creators and the consumers of the material. Fortunately, however, prior studies of car culture can provide insight into factors relevant to how the car guy subculture is intertwined with hegemonic masculinity. Walker et al. found an inverse correlation between boys' interest in cars and school among the working class, suggesting that weak academic performance prompted the youth to seek "power and authority... denied them in most other realms" . Similarly, Hatton found that car culture was alluring to unemployed or underemployed young men who sought to boost their masculinity in response to feeling otherwise devalued. In addition, there is some evidence that "boy racers" of higher social classes are considered effeminate by their working-class counterparts . Thus, car culture may confer manhood to compensate for feelings of "exclusion from the labor market and exclusion from the academic curriculum" : The appeal of a racecar is apparently so palpable that it arguably serves as a form of "autoeroticism" . "[M]otor vehicles provide a cultural medium in which young men, whether or not they are physically small, labeled "dumb" by others, or are from a vilified ethnic or racial group, can demonstrate masculine strength, virility, and prowess: their technical ability to control a 'performance' motor vehicle at high speed and their courage and daring through risk-taking" . Missing from Walker et al.'s insightful analysis quoted above, however, is the aspect of the corporeality of cars as a surrogate human body. In this regard, research on athletes is relevant. When amateur rugby players' bodies fell short according to a masculinity yardstick, the resulting threat to their identity as team members resulted in embodied remedial identity work, in which various means of using their bodies served to reclaim hegemonic masculinity . Likewise, in car reviews, masculinity may be equated with a car in its physical form. "Rumble Seat" columnist Dan Neil described his experience test driving a "fantasy automobile, " the McLaren 765LT retailing for $429,000 and boasting 755 horsepower . Neil touts its "muscularity... tendons and sinews" commenting, "I felt like handing it a robe, " implying that its body reminded him of a muscular naked man that "creates a vortex of attention" . Similarly, with car guys, the car serves as an extension of the body that both projects masculinity and provides an alternative means to attain status, especially in the absence of other accessible avenues to achieve recognition. --- Notes on methods Memes offer an opportunity to gain insight into the members of a subculture, a method that avoids social desirability bias in which research participants may feign support for politically correct views or alter their behavior when under observation . Furthermore, standard data collection methods cannot avoid major limitations in attempts to tap into inner thoughts . It must be emphasized that the 60 memes analyzed in this paper are only a snapshot of data available in November 2021 and are not intended to suggest a monolithic hegemonic archetype of the "car guy" subculture. The variations and progress in addressing hegemonic masculinity emphasize the importance of documenting masculinity in a variety of contexts, longitudinally . Furthermore, the ever-changing cultural context relevant to car culture will inevitably lead to new memes that reflect the changing zeitgeist. The car's tremendous engine power is linked to its initials, LT meaning longtail, a likely nod to tail as sexually suggestive, including one meaning as slang for sexual intercourse. Despite the limitations of the methodology employed, these memes show how flashy cars may serve as an outlet for men to express repressed fantasies of power, freedom, visibility, respect, and sometimes domination. Thus, car culture permits escapism in the form of socially sanctioned passion for cars in which men conflate their identity with that of a powerful car. The value of a muscle car projects strength that exemplifies corporeal masculinity as a cultural performance, conveying autonomy that minimizes or disparages any power that women have over men. By identifying with their cars and idolizing traits associated with ostentatious vehicles, men circumvent reliance on women for validation while gaining stature in the eyes of other men or at least other car guys. --- Conclusion The body of memes presented in this paper reveals that masculinity can be expressed in material resources wherein a car embodies characteristics of hegemonic masculinity, namely features that car guys seek to emphasize. Cars also may symbolically substitute for women, projecting masculine control and independence, an antidote to women as the proverbial "ball and chain" that is a metaphor for women who constrain men's freedom and control the fulfillment of their libidinous needs. In that sense, showy cars can celebrate single life, nostalgia for single life, and the ability to spend uninterrupted time on pursuits that affirm masculinity. While this desideratum is not novel, its sustained resonance as expressed in memes shows resistance to gender parity and the long road still ahead. Rather than expend energy and risk rejection by dating, a young man can gain status from cars. This perspective is visible in memes, especially those that belittle women to justify why cars are an attractive substitute for women. These memes ultimately reflect ambivalence about committed relationships and the attendant responsibilities that detract from leisure time, freedom, and independence. By defining their masculinity relative to their cars, car guys ultimately feel a greater sense of control compared to depending on women to validate virility. In the future, car guy memes may become less focused on themes of escaping responsibility and asserting masculinity. Similarly, the genre of "car guys" could evolve to be more gender inclusive, to reflect all individuals who are car aficionados, removing aspects of gender from the insider-outsider appeal of the subculture. --- Data availability statement The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author. --- --- --- Publisher's note All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

The construction of gender identities occurs through a variety of social forces, including memes widely circulated on social media. Beyond the function of internet memes as entertainment, they also promote gender-based bonding through humor in ways that encourage performative gender roles central to self-image. Decoding memes as a form of contemporary data reveals desires and fears, both conscious and unconscious, that underlie dramaturgical performances supporting hegemonic masculinity. In the case of "car guys," car aficionados whose passion for cars is integral to their identity, memes reflect the group's aspirational presentation of self, including cars, as a symbolic physical embodiment of hegemonic masculinity. This semiotic study of car guy memes shared on social media uncovered recurrent motifs centered around cars' ability to a rm men's position in the metaphorical driver's seat. Flashy cars were often portrayed as more desirable than women, a sentiment encapsulated by the meme, "Men love women, but even more than that, men love cars." This novel analysis of memes explores the ostensible male preference for fantasy cars over emotionally risky relationships. Two salient themes relevant to conceptions of masculinity emerged: ( ) car guys' apprehensions about male-female interdependence and ( ) frustration with women's discretion in meeting men's emotional and sexual needs. Memes as a cross-sectional, unfiltered data source provide insight into the need to reconcile car culture with gender equality.

Introduction During the COVID-19 pandemic, the number of netizens aged 60 and older in China doubled, surpassing 123 million [1,2]. This sharp increase can largely be attributed to the necessity of using the internet to obtain a Health Code . To determine an individual's exposure risk for COVID-19, the Chinese health agencies tracked an individual's travel history, time spent in high-risk areas, and close contact with potential COVID-19 carriers through the Health Code [3]. When people visit hospitals or other public places, they must show their Health Code. Internet usage is closely related to daily health accessibility, engagement with social activities, and the aging process. Havighurst proposed the concept of successful aging and defined it as older people obtaining the maximum satisfaction from life [4]. Rowe and Kahn advocated that aging should not primarily be addressed as a process of rapid decline and increasing limitations, thus refining the concept of successful aging [5,6]. They distinguished successful aging from usual aging and defined successful aging as avoiding disease and disability, high cognitive and physical functioning, and active engagement with life [5,6], which has been widely used in prior studies [7]. With the internet becoming increasingly ubiquitous in people's lives, many studies, even those not based on the concept of successful aging, have examined the relationship between internet use and older people's health outcomes or engagement with life [8][9][10][11][12][13][14][15][16][17][18][19][20]. Specifically, regarding health outcomes, a symmetry analysis argued that internet use has a great potential to successfully change the lifestyle of older people aged 50 years or over and promote a healthier body at a very low cost [8]. Prior empirical studies revealed that internet use could provide significant health benefits to older people, including accumulating a wealth of health resources, improving cognitive abilities, and delaying dementia onset [9][10][11][12]. Some studies also found that internet use could efficiently decrease depression risk and predict a higher level of subjective well-being and mental health [13][14][15][16]. Moreover, regarding engagement with life, some studies found that older netizens had a more active engagement with life, such as involvement in community activities, volunteering activities, and political participation, compared to non-netizens [17][18][19][20]. Despite the results in prior literature providing guidelines for exploring the association between internet use and older Chinese people's aging process, several gaps remain. First, although prior studies have revealed the relationship between internet use and older people's health or engagement with life, few attempts have been made to examine the relationship between internet use and successful aging and theoretically and empirically explore the potential mediator through which internet use relates to older people's aging process. Second, gender is a vital social lens [21]. The successful aging of older women and its influencing factors remain under-focused and unexplored in the literature. While women generally have an advantage in lifespan [22], they might experience poverty and ill health in old age due to poor access to education, meaningful work, and health services when younger [23]. Furthermore, approximately two-thirds of the population over the age of 75 in most developing countries comprises women, and an aging society may gradually reflect the feminization of aging [21]. Therefore, it was necessary to integrate a gendered perspective into this research. Third, some quantitative studies have neglected the endogeneity problem between internet use and health or engagement with life, which might produce an estimation bias. In this study, the instrumental variable approach was used to address the endogeneity problem between internet use and the successful aging of older women. Therefore, the aims of this study are to clarify the relationship between internet use and the successful aging of women aged 60 years and over in a Chinese setting and to elicit the potential mediator through which internet use is associated with successful aging of older women. To realize the above aims, we used the nationwide dataset of the China Longitudinal Aging Social Survey 2016 conducted by Renmin University of China. This study contributes to the literature in three ways. First, by integrating a gender perspective, this study enriches the literature on the determinants of older women's aging process by adopting a nationally representative dataset from China. Second, this study investigates the mechanism of social capital through which internet use is associated with the successful aging of older women. In this way, we connected internet use with the successful aging of older women theoretically and empirically. Third, the findings in this study can aid policymakers in formulating targeted aging policies for women in developing countries and regions. The remainder of the paper is organized as follows. Section 2 presents the theoretical framework and hypotheses. Section 3 provides a description of the CLASS2016 dataset, measurements, and empirical model. Section 4 shows the empirical results. Section 5 includes the discussion and policy implications, and Section 6 states the conclusions. --- Theoretical framework and hypothesis development The framework of older women's successful aging Successful aging is a multidimensional concept that involves achieving an optimal physical, mental, and social state of well-being for older people [24]. Nonetheless, an agreement on the specific definition and operationalized criteria of successful aging has yet to be reached, and the definition and operationalized criteria of successful aging have varied among studies [7]. Some research has argued that successful aging can be measured in both objective and subjective ways [7,25]. Objective factors can include older people's overall health and socioeconomic conditions, while subjective factors include life satisfaction and self-rated physical decline [26]. The most influential conceptualization of successful aging to date was proposed by Rowe and Kahn [27,28], who defined it as avoidance of disease and disability, high cognitive and physical functional capacity, and an active engagement with life [5,6]. Among these three specific components, avoidance of disease and disability represents the absence of disease, disability, and related risk factors. High physical and cognitive functional capacities include the potential for an activity. Active engagement with life mainly concerns the engagement forms of interpersonal relations and productive activity [5,6]. Rowe and Kahn's conceptualization of successful aging has been used as a "calculable gold standard of aging" in many empirical studies today [28,29]. Therefore, according to the framework of Rowe and Kahn for successful aging [5,6] and prior Chinese studies [25,27,30], successful aging in the current study has been defined as no major diseases, no disability, high cognitive functioning, high physical functioning, and active engagement with life . --- Internet use, successful aging, and the mediation effect of social capital Social capital contributes vital instrumental and emotional resources to the successful aging of older women [31]. Social capital is generally viewed as a resource that can be obtained from individual social networks, and it explains how positive social networks advance individual development by allowing a person to believe that he or she is cared for, loved, esteemed, and valued [32][33][34][35]. Prior studies have mainly employed the size of supportive social networks to measure individuals' social capital, and results have shown that the higher the level of individual social capital, the more likely the individual is to obtain more instrumental resources, such as wealth and medical resources, to prevent disease and maintain good mental health [36][37][38][39]. Additionally, a higher level of social capital also provides emotional resources, such as increasing person-to-person contact and extending the friend range so as to promote active social interactions and engagement with life [40,41]. Thus, a higher level of social capital is conducive to the realization of successful aging. In the current study, we also obtained the social capital of older women through the size of their supportive social networks [36][37][38][39]. Moreover, empirical studies have found that, compared with older men, social capital has stronger positive associations with older women's health and engagement with life [42][43][44]. This difference can be attributed to the fact that compared to men, women are more willing to spend time preserving and promoting their existing positive social networks among friends and families. Ultimately, women tend to obtain more instrumental and emotional resources from their social capital than men, allowing them to maintain good health and actively engage with life [45]. Thus, social capital is an essential resource for older women to have in order to achieve successful aging. Internet use may be associated with the successful aging of older women through the mediation of social capital. The internet offers convenience, connectivity, and ubiquity and dismantles the restrictions of kinship and geography on social interactions [46]. Thus, internet use efficiently enhances the frequency of contact between older women and younger generations and promotes communication among older people [45]. Moreover, internet use provides users with opportunities to make new friends and expand their social networks [47]. Therefore, internet use can increase social capital among older women. As illustrated by the above discussion, social capital may play a mediating role in the overall association between internet use and the successful aging of older women. Accordingly, we propose the following hypotheses: Fig. 1 The successful aging framework of the older Chinese women internet use is positively associated with successful aging for older Chinese women , and social capital can mediate the relationship between internet use and successful aging for older women . --- Methods --- Data The data employed in this study are from CLASS2016, a nationally representative dataset focusing on people aged 60 and over in China. The dataset was compiled by the China Survey and Data Center at Renmin University of China. It is a nonprofit survey, and respondents answered anonymously to protect their private information. The main content of CLASS2016 comprises respondents' personal characteristics and family characteristics . CLASS2016 includes respondents from 28 provincial administrative units in China and serves as a source for studying aging issues in the Chinese context. Samples with invalid answers and missing answers were excluded. Consequently, 2713 valid female observations were included in this study. --- Measurements --- Explained variable According to the theoretical framework, we defined successful aging of older women as having no major diseases, no disability, high cognitive functioning, high physical functioning, and active engagement with life . We operationalized the five specific measures as follows. No major diseases. Respondents were asked whether they had been diagnosed with any major chronic diseases . A measure of mental health was also included. Mental health was measured using a nine-item Center for Epidemiological Studies Depression scale, which was validated in a prior study on older adults' mental health [48]. The positively worded items in the nine-item CES-D scale were reversed, and all items were summed . Thus, the nine-item CES-D scale ranged from 0 to 18, and a higher score on the scale indicated more depressive symptoms and worse mental health. Based on prior studies on the mental health of older Chinese people [30,49], we adopted nine as the cut-off point for the nine-item CES-D scale. Thus, when respondents did not report any major chronic diseases and obtained a score of nine or below on the nine-item CES-D scale, they were regarded as meeting the no major diseases criterion and coded as 1; otherwise, 0. No disability. Based on previous studies [27,30], no disability was measured by items on basic activities of daily living and instrumental activities of daily living . The BADL items included grooming, dressing, bathing, eating, toileting, getting in and out of bed, and continence. The IADL items include phoning, indoor transferring, financial management, public transport, and shopping. Respondents who had no impairment in any items in the BADLs and IADLs met the no disability criterion and were coded as 1; otherwise, 0. High cognitive functioning. The cognitive functioning assessment developed by CLASS2016 used 16 questions to test older women's language, nonverbal memory, verbal memory, and conceptualization ability. The response to each item was coded 1 for a correct answer and 0 for a wrong answer. Thus, cognitive functioning assessment scores ranged from 0 to 16. Respondents whose sum scores were at the median or higher were considered to achieve the high cognitive function criterion and were coded as 1; otherwise, 0 [28,30]. High physical functioning. Respondents who had no difficulty in performing each of the five activities of physical functioning were regarded as reaching the high physical functioning criterion and were coded as 1; otherwise, 0 [27,50]. Active engagement with life. Respondents who were currently engaged in either productive activities or non-productive activities were considered to meet the active engagement with life criterion and were coded as 1; otherwise, they were coded as 0 [28,30,50]. Successful aging. Using the five measures described above, older Chinese women who met all five criteria were regarded as successful agers and were coded as 1; otherwise, 0. --- Explanatory variable Internet use frequency was the key explanatory variable in this study and was measured by the question, "How often did you use the internet in the past three months?" The answers were given as a number on a five-point Likert scale ranging from 1 to 5 . --- Mediating variable As mentioned above, social capital may play a mediating role in the relationship between internet use frequency and successful aging among older women. Therefore, social capital was the mediating variable. Social capital was assessed as a continuous variable, and it was obtained through the total size of the supportive social network, including the number of family members/friends an older woman meets or contacts, the number of family members/friends with whom older woman can confidently discuss private affairs, and the number of family members/friends who can provide help when older woman needs [36][37][38][39]. --- Control variables To precisely clarify the relationship between internet use frequency and the successful aging of older women, we controlled for variables that may affect successful aging. These control variables included older women's age , marital status , education , household registration , number of children, living environment , industry , logarithm of total income , and lifestyle of regular exercise [51][52][53][54][55][56]. In addition, we controlled for regional effects by province. According to the regional division proposed by the National Bureau of Statistics of China [57], the provinces where respondents lived were divided into four categories: eastern, central, western, and northeast regions. Thus, the province was added to the model as a categorical variable. A descriptive analysis of the aforementioned variables is presented in Table 1. --- Empirical model The explained variable of successful aging was binary; thus, the binary probit model was adopted as the baseline model to analyze the relationship between internet use frequency and the successful aging of older women and verify Hypothesis 1. The baseline binary probit model can be expressed as follows: where Successful aging * represents older women's aging status, which is an unobservable latent variable. Internet use frequency is an observable explanatory variable. Z contains a set of control variables. β 0 indicates the constant, and β 1 and γ are the parameter vectors to be estimated. ε is a random disturbance term that obeys a normal distribution. Successful aging * = β 0 + β 1 Internet use frequency + γZ + ε The relationship between the latent variable of Successful aging * and Successful aging can be expressed as follows: Although the baseline binary probit model can indicate the association between internet use frequency and the successful aging of older women to a certain extent, endogeneity remains a considerable problem that needs to be solved. First, although most of the factors affecting older women's successful aging were controlled for, some unobserved confounding factors could simultaneously affect older women's internet use behavior and successful aging. Second, the baseline binary probit model is prone to measurement error due to social desirability bias [58]. Thus, to minimize the confounding problem and measurement error, we replicated our baseline analysis by using the IV approach, viz., instrumental variable binary probit model [59]. The IV-probit model can be summarized into two stages [58,60]. The first stage involves estimating the main predictor by using an instrument and a set of control ( where Instrument is the instrumental variable. δ 0 is a constant, and δ 1 is the coefficient of the instrumental variable. θ represents the coefficients of the control variables. ϵ is a random disturbance term. The second stage involves estimating the latent variable of Successful aging * using the value of internet use frequency that was predicted in the first stage. where μ 0 is a constant, and μ 1 is the coefficient of Înternet use frequency . η indicates the coefficients for the control variables and σ is a random disturbance term. Successful aging * and Z have the same meanings as those in Equation . In this study, the provincial internet penetration rate in 2015 was chosen as the instrument. The provincial internet penetration rate is the number of internet users in the province divided by the total provincial population, which is an appropriate IV satisfying the requirements of relevance and exclusion [61]. Regarding relevance, individual internet use behavior is closely associated with the level of internet penetration in a region. Regarding exclusion, according to the ratchet effect, the internet infrastructure within a region is the result of a long period of construction, which is irreversible and does not directly affect older women's successful aging. In the Results section, the IV was tested to validate its reasonableness, including the tests of weak identification and under-identification, the Wald test of exogeneity, and the F value of the first stage. Furthermore, to explore the influential mechanism and demonstrate support for Hypothesis 2, a binary probit model based on the KHB mediation analysis as proposed by Karlson, Hom, and Breen was employed. The KHB mediation method compares the full model with a reduced model that substitutes the residuals of the mediator from a regression of the mediator on the key variables [62,63]. This method extends the decomposition properties of linear models to nonlinear probability models, and enables the separation of the change in the coefficient due to either confounding or rescaling [62,63]. STATA 15.0 was used to perform the data analyses in the current study . Internet use frequency = δ 0 + δ 1 Instrument + θ Z + ǫ Successful aging * = µ 0 +µ 1 Internet use frequency + ηZ + σ --- Results --- Descriptive analysis A descriptive analysis of all the variables is reported in Table 1 . Regarding the explained variable, the mean value of successful aging was 0.173 , indicating that 17.3% of the older Chinese women in our sample met all five measures of successful aging and were successful agers. Concerning the five specific measures of successful aging, the mean value of no major diseases was 0.401 , which suggested that the ratio of participants who met the no major diseases criterion was 40.1%. The measure of no disability had an average value of 0.699 , indicating that the proportion of those who met the disability criterion was 69.9%. The mean values of high cognitive and physical functioning were 0.927 and 0.804 , respectively. The results indicated that the ratios of participants who met the criterion of high cognitive and high physical functioning were 92.7 and 80.4%, respectively. Finally, the measure of active engagement with life had a mean value of 0.588 . The results indicated that 58.8% of the older Chinese women in our sample actively participated in non-productive or productive activities. The explanatory variable of internet use frequency had an average value of 1.415 . This result suggested that the older Chinese women in our sample were relatively inactive in using the internet. In terms of the control variables, the mean age of the sampled older women was 69.963 , and 61.9% were married. The average educational attainment of the older respondents was 6.467 years , which was approximately the level of primary school. A total of 59% of the sampled women were urban residents, and the average number of children that the sampled women had was 1.381 . The mean value of the living environment was 0.778 , and of the sampled individuals, 51.1% engaged in nonagricultural industrial work before retirement. The average value of the logarithm of total income was 9.187 , and 18.1% of the respondents had a regular exercise habit. The mean value of the mediating variable social capital was 14.766 . The mean value of the IV was 0.525 , suggesting that the average provincial network penetration rate for provinces where the sampled older women lived in 2015 was 52.5%. --- Results of the baseline regression and instrumental variable regression Table 2 presents the results of the baseline and IV regressions. As shown by the baseline binary probit model results in Table 2, the coefficient of internet use frequency is significant and positive . This indicates that, with other factors being certain, an increase in internet use frequency is associated with an increase in the probability of being in the successful aging status by three percentage points. The coefficient of internet use frequency is again significant and positive when employing the IV-probit model, suggesting that an increase in internet use frequency is correlated with an increase in the probability of being in a successful aging status by approximately 29 percentage points. The above results confirm Hypothesis 1-that the higher the internet use frequency, the more likely older Chinese women are to be in a successful aging status. In addition, the coefficient of internet use frequency, estimated using the IV-probit model, is approximately ten times higher than that estimated using the baseline binary probit model. This underestimation can be attributed to the fact that the baseline binary probit model considerably underestimates the effect of internet use frequency due to confounding problems and measurement errors [58,64,65]. Table 2 also reports the reasonableness of the IV. First, the Cragg-Donald Wald F statistic and Kleibergen-Paap rk Wald F statistic are 65.432 and 77.227, respectively. These statistics are significantly higher than the Stock-Yogo weak IV test critical value of 16.38 [66]. Therefore, the null hypothesis that the provincial internet penetration rate is a weak IV is rejected. Second, the Kleibergen-Paap rk LM statistic is 65.951 , and the first-stage F statistic is 77.230 . The above results indicate that IV is closely related to the endogenous explanatory variable . Finally, the result of the Wald test of exogeneity significantly reject the null assumption that internet use frequency is an exogenous variable, which means that the IV-probit results should be chosen over the results of the baseline binary probit, which might suffer from confounding problems and measurement errors. The above results of the IV tests provide evidence that the IV is valid, and the estimated equations are correctly specified. --- Robustness checks --- Subgroup regression The full sample was categorized into rural and urban samples based on household registration. The respondents were divided into two subgroups according to marital status: married and other. Considering the industry in which respondents engaged before retirement, the sampled older women were placed into two subgroups: agricultural and nonagricultural. The results of the six subgroups regressions using the IV-probit models are presented in Table 3. The results show that the coefficients of internet use frequency in the rural and urban groups , and those in the married and other groups, are positive and significant. In addition, the coefficients of internet use frequency in the agricultural and non-agricultural groups are also positive and significant. Thus, the results that internet use is positively associated with successful aging for older Chinese women are valid across different subgroups. --- Testing the relationship between internet use frequency and the five specific measures As the five specific measures of successful aging were binary, using the IV-probit models to estimate the relationship between internet use frequency and the five specific measures of successful aging is appropriate. The specific procedure of IV-probit models estimating the five specific measures is the same as that used to estimate successful aging. The results are estimated using the IV probit model, as presented in Table 4. The results show that internet use frequency is positively and significantly correlated with no major diseases , no disability , high cognitive functioning , high physical functioning , and active engagement with life . These results indicate that the Hypothesis 1 of our study is maintained again. --- Functional mechanism analysis After the positive association between internet use frequency and successful aging of older women was verified, the potential mechanism through which internet use frequency was correlated with successful aging of older women was tested. The results of binary probit model based on the KHB mediation test on social capital are presented in Table 5. The results in Table 5 show that, the --- Discussion During the COVID-19 pandemic, the internet-based Health Code became a major part of people's lives and is a vivid and incisive reflection of the influence of the internet on older people in China. When older people take public transport , access public places, and migrate across provincial boundaries, they must show their Health Code. As a result, the number of netizens aged 60 years and older in China surged in 2020 [1,2]. Internet use has become an important part of the aging process of older people. In this context, it is of practical significance to explore the relationship between internet use and aging. Previous studies have focused on the association between internet access and a single aspect of older people's aging, such as health outcomes or engagement with life [10][11][12][13][14][15][16]. However, this study investigated the relationship between internet use frequency and multidimensional components of successful aging among older Chinese women, based on Rowe and Kahn's framework of successful aging. The results found a positive relationship between internet use frequency and successful aging of older Chinese women. The results further indicated that social capital partially mediated the overall association between internet use frequency and successful aging. Internet usage shortens the geographical and social distances among individuals and enables older women to communicate with their children, relatives, and friends thousands of miles away [67,68]. In particular, the voice messaging function of internet-based applications, such as the voice chats in WeChat and QQ, greatly promotes communication between older people and the younger generation, advances the removal of barriers posed by age segregation, and shrinks the gaps between generations [69]. Furthermore, internet usage broadens the ability of older women to acquire health-related knowledge, self-display, strengthen social connections, expand social capital, and consequently achieve a successful aging process. As of April 2021, TikTok creators aged 60 and over had made more than 600 million videos on the platform, with content including the display of lifestyles and interactions between parents and children, which had received over 40 billion "likes" in total [70]. Based on the findings of this study, active usage of the internet is one of the keys to achieving successful aging of older women. Therefore, some policy recommendations based on internet use can be proposed to provide external support for the successful aging of older women. First, older people's internet use difficulties still deserve our attention, especially among older women who have historically been denied access to educational resources in some developing countries and regions. To meet most of the needs of older women in using the internet, suppliers of digital devices should try to design smartphones or laptops that are affordable, easy to carry, easy to access the internet, rich in functions, and especially easy to operate. Second, because a sustained preference for sons and discrimination against daughters has been more efficiently maintained in some undeveloped rural areas, older women in rural areas are less educated and have more vulnerable livelihoods than men and urban women. In the subgroup regression, we found that internet use frequency is significantly and positively associated with successful aging of both urban and rural older women. Thus, to advance the successful aging of these rural older women, elderly care services or poverty alleviation measures of relevant departments can consider subsidizing the purchase of smartphones, and recruiting volunteers to teach them how to use smartphones to facilitate internet usage for older women in undeveloped rural areas. Third, women could be more easily addicted to social networking services than men [71]. While internet use is largely beneficial for older women's successful aging, there is an increasing number of female senior citizens with smartphone addiction, such as long-term Tik-Tok browsing and overuse of multimedia applications. Moreover, women, especially older women, can be victims of online scams [72,73]. Therefore, the government and relevant institutions can guide older women in appropriate internet usage to prevent internet addiction and improve their awareness of internet fraud. This study has limitations that should be considered. First, considering that internet overuse may result in adverse effects on older people, we tested the inverse U-shaped relationship between the internet use frequency and successful aging of older women. The results of the U-test indicated that the extreme point was not included in the range of the explanatory variable, thereby failing to reject the null assumption of monotonicity. However, the monotonic relationship between internet use frequency and older people's successful aging needs to be further examined. Second, the data used in this study were crosssectional rather than panel data; thus, we could not observe dynamic changes in the relationship between internet use frequency and successful aging of older women. In the future, research can employ panel data to test this. Third, older women can use the internet either adaptively or maladaptively. However, due to data availability restrictions, we cannot identify older people who use the internet in adaptive or maladaptive ways in CLASS2016. Future research could explore the different effects of adaptive and maladaptive methods of internet use on older women's aging processes. Fourth, restricted by data availability, we only reported the mediating effect of social capital on the relationship between internet use frequency and successful aging among older women, while internet use is associated with multiple purposes beyond social communications. Thus, social capital is not the only possible mediator. Future studies can explore other potential mediators. --- Conclusion The internet has become almost ubiquitous in all aspects of contemporary human life. However, little is known about the association between such profound technological developments and older people's aging, especially older women. This study offers preliminary evidence that internet use is associated with the aging process of older women in China. Based on the framework of successful aging proposed by Rowe and Kahn, we used a nationwide dataset and found that the positive association between internet use frequency and the successful aging of Chinese women aged 60 and over was valid across different models. Moreover, social capital partially mediated the relationship between internet use frequency and successful aging of older Chinese women. The findings enrich the literature on the determinants of successful aging of older women and aid policymakers in formulating targeted aging policies for older women in developing countries and regions. --- --- Abbreviations Authors' contributions Y.J. proposed the idea of this paper, developed the method, and wrote the theoretical analysis, the results, discussion, and conclusions. F.Y. provided guidance in the theory and modified and edited the whole manuscript. All authors have read and agreed to the published version of the manuscript. --- --- --- Competing interests The authors declare that they have no competing interest. ---

The internet has become ubiquitous in contemporary human life. However, little is known about the association between internet use and older people's aging process, especially that of older women.Using the nationally representative dataset of the China Longitudinal Aging Social Survey 2016, we examined the relationship between internet usage and the successful aging of older Chinese women. The sample in this study consisted of 2713 respondents with an average age of 69.963 years. Successful aging was defined as no major diseases, no disability, high cognitive functioning, high physical functioning, and active engagement with life. Older women's internet use behavior was represented by internet use frequency. Probit and instrumental variable models were employed to test the association between internet use frequency and successful aging of older women. The Karlson/Holm/Breen (KHB) mediation analysis was used to estimate the mediating effect of social capital on the relationship between internet use frequency and older women's successful aging. Results: Using a probit model (coefficient = 0.030, p < 0.001) and an instrumental variable probit model (coefficient = 0.287, p < 0.001), it was found that a successful aging status was significantly correlated with an increase in internet use frequency. The functional mechanism analysis suggested that social capital partially mediated the overall association between internet use frequency and successful aging.This study suggests that the more frequently older Chinese women use the internet, the greater the possibility of successful aging. Our findings provide new evidence from China about the determinants of older women's aging process and aid in formulating targeted aging policies for older women in developing countries and regions.

Introduction The association between alcohol use disorder and subsequent psychosocial dysfunction has been long commented upon and noted empirically since the seminal study of Faris & Dunham . These results have been repeatedly replicated as recently as the 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III . Less clear have been the causes of this association. Often framed as the 'drift v. stress' controversy, two leading positions have been that the 'stress' of low socioeconomic status predisposes to AUD or AUD and its clinical and medical consequences cause psychosocial dysfunction and a downward 'drift' in SES. An alternative third hypothesis should be considered -that the association of low SES and AUD is not causal but rather the result of a range of confounder variables that predispose to both conditions . There is fairly robust support for the stress hypothesis. Evidence here includes a recent Swedish study that found low childhood SES was associated with later AUD , even after accounting for parental psychosocial problems including alcohol and drug abuse, and another study finding a causal link between neighborhood deprivation and drug use disorders which also utilized Swedish population register data. Evidence for the drift hypothesis comes from studies documenting long-term sequelae of heavy substance use and AUD including unemployment , incarceration , poverty , and homelessness . For example, Buu et al. found that after conviction for driving under the influence , men with active AUD were more likely to live in disadvantaged neighborhoods over a 12year period than their similarly convicted peers who either did not have AUD or were in remission from AUD. Evidence for the stress and drift hypotheses can be difficult to disentangle due to study limitations including cross-sectional designs and small samples, which often restrict adequate control of confounding factors. In this report, we seek to clarify the magnitude and nature of the association between AUD and subsequent psychosocial dysfunction . To do this, we implement a longitudinal cohort design supplemented by co-relative analyses using data from Swedish national registries. We further enrich our approach by using four distinct outcome variables which reflect different aspects of psychosocial dysfunction: early retirement, unemployment, receipt of social assistance, and individual income at age 50. To build on prior research in this area, we are particularly interested in determining the degree to which this AUD-drift association arises as a direct consequence of AUD v. familial confounding. We first calculate the prospective association between registration for AUD, as assessed from national medical, criminal and pharmacy registries, with each of these outcome measures. Second, we examine the attenuation in these associations when we add to the predictive model three important confounding variables: family SES, neighborhood social deprivation, and early externalizing behaviors. Third, we explore associations between AUD and early retirement, unemployment, social assistance, and individual income in the general population and in pairs of cousins, half-siblings, siblings, and monozygotic twin pairs discordant for AUD. The goal of these co-relative analyses is to determine the degree to which the association observed in the population is attenuated as we control for increasing background genetic and familial-environmental factors in our co-relative pairs. --- Material and method --- Measures We collected information on individuals from Swedish population-based registers with national coverage. The registers were linked using each person's unique identification number. To preserve confidentiality, this ID number was replaced by a serial number. AUD was assessed using information from several registers . In short, we identified AUD cases using ICD codes for primary and secondary diagnoses recorded in inpatient and outpatient care registries; prescription drug information on common pharmacotherapies received for AUD; and crime data on convictions for DUI. The main outcome variables in this report are collected from the Swedish Longitudinal Integration Database for health insurance and labor market studies from 1990 to 2009 and are defined as follows: Social assistance is categorized into a binary variable based on whether or not the individual has received any social assistance during a given year. Social assistance is defined as financial support under the Swedish Social Services Act, which is designed to provide support for an individual's upkeep and for other items so as to provide a reasonable standard of living. Examples of common situations when social assistance is given include: income supplements for low-income families; for unemployed persons when other unemployment assistance is not provided or is insufficient; when sickness benefits are insufficient or not provided; and to those who are bound by the children in the home and cannot get childcare and therefore cannot seek work. The variable is recorded at the family level, which means that all individuals in a family with social assistance will, in this report, be counted as recipients of social assistance. Early retirement is categorized into a binary variable based on whether or not the individual has received any early retirement during a year. Early retirement is a combination of several different variables from the Swedish registers. Until 2002, Early Retirement Pension was paid to people aged 16-64 and granted when their working capability was deemed to be permanently reduced by at least one quarter due to medical reasons. The early retirement variable is also composed of temporary disability pensions paid to individuals whose working capability was not expected to be permanent but was expected to persist for a considerable time. From 2003, the rules for Early Retirement Pension and Temporary disability pension changed and these types of compensations were changed into sickness compensation and activity compensation . The qualification rules were similar but activity compensation was supposed to be limited in duration. Unemployment is categorized into a binary variable based on whether or not the individual received any unemployment benefits during a given year. In order to be entitled to unemployment benefits the following requirements need to be fulfilled: the individual is unemployed ; able to work at least 3 h a day and 17 h a week; registered as a jobseeker at the Employment Service; prepared to take the offer of suitable work or employment; and actively seeking a suitable job. Income at age 50 is defined as the disposable income for the individual at age 50. In order to be able to compare the variable over time we have standardized the variable by gender and year of birth. In the registers, disposable income is defined as total personal income minus personal current taxes. --- Sample and statistical methods The database included all individuals born in Sweden 1945-1965 for whom we had yearly information for the four outcome variables between 1990 and 2009. For the early retirement, social assistance, and unemployment analyses, we used Cox regression models to investigate the risk for these outcomes in individuals as a function of their first AUD registration during the follow-up period. As the first registration for AUD could occur at different time-points, we treated AUD as a time-dependent variable, i.e. from start of follow-up until the year the individual was registered for AUD, this individual was considered free of AUD, while from the year of AUD until end of follow-up, this individual was considered registered for AUD. Robust standard errors were used to adjust the 95% confidence intervals because the sample contained individuals from the same family. In order to ensure that the onset of AUD occurred prior to the studied outcome, we made some particular restrictions for each analysis. For the early retirement analysis, we excluded individuals with a registration in 1990 and 1991. Even though the definition of early retirement states that it could be limited in time, only 4% of the individuals that were registered for early retirement in our dataset did not continue receiving early retirement benefits until the end of the study period. In the social assistance and the unemployment analysis, in order to ensure that the registrations reflected the first time these benefits were received and that this occurred after the AUD registration, we excluded individuals with a social assistance or unemployment registration between 1990 and 1997. We also excluded individuals with an early retirement registration during 1990-1997, as those individuals were not eligible for unemployment or social assistance. Hence, in the early retirement analysis, the follow-up time starts in 1992, while in the social assistance and unemployment analyses it starts in 1998. The follow-up time ends in 2009, year of death, year of emigration or year of early retirement . For the income analysis, we used Ordinary Least Squares including all individuals registered with a disposable income at age 50. In this model, we required that the AUD registration occurred prior to age 50. Note that the youngest individuals in this group were born 1959. The modeling approach was identical for the four variables of interest. In model 1 we only included AUD registration as a predictor. In model 2 we also included age, highest achieved educational status, neighborhood social deprivation and, as indices of prior externalizing behaviors, a history of either criminal behavior or drug abuse prior to age 25. . Model 3 also included prior AUD. This variable was defined as an AUD registration prior to start of the follow-up period in the models for early retirement, social assistance and unemployment. For income, we divided the prior AUD variable into two groups: registration between ages 40-50 and/or registration prior to age 40. Next, we sought to assess the degree to which the results from model 1 reflect confounding by familial risk factors using a co-relative design. Using the Swedish Multi-Generation Register and the Swedish Twin Register, we identified all MZ twin pairs, all full-sibling sets, all half-sibling pairs, and all first-cousin pairs. For early retirement, social assistance and unemployment, we used a stratified Cox regression model, in which we refit all analyses within strata of the defined relative sets . Only relative sets in which the members differed in their exposure to AUD at some age would contribute to the regression estimates . Within each stratum, the hazard ratio is adjusted for the familial cluster, and, therefore, accounts for an array of unmeasured genetic and environmental factors shared within the relative set. For income, we used fixed effects linear models with a separate intercept for all relative sets. For each of the four outcomes, in the next step, we combined all five samples into one dataset. On this dataset we performed two analyses. The first allowed all parameters for each sample to be independent. In the second, we modeled the interaction between genetic resemblance and AUD. We assumed that this parameter followed the genetic resemblance for each relative sample; i.e. 0 for the population, 0.125 for the cousins, 0.25 for the half-sibling, 0.5 for the sibling, and 1 for the MZ twin sample. Hence, the second model included two parameters: a main effect for AUD and the interaction term. We compared this model, using Akaike's Information Criterion for the Cox hazard models and extra sum of squares F test for the linear regression models, with the previous model. If the second model fitted the data well, we obtained a slope for the familial confounding as well as an improved estimation of the association among all relatives, but especially MZ twins, where the data were often quite sparse. All statistical analyses were performed using SAS v. 9.3 . --- Ethical standards The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. We secured ethical approval for this study from the Regional Ethical Review Board of Lund University . --- Results --- Sample characteristics For examining the association between AUD registration and subsequent early retirement, unemployment and social assistance, we studied all eligible individuals born in Sweden from 1945-1965. For income, our cohort ended in 1959. As outlined in Table 1, sample sizes in males and females ranged from 6 70 000 to 1.1 million. Across the cohorts, AUD was three to four times more common in men than women. Note that compared to the unemployment and social assistance cohorts, the early retirement cohort has the least restrictions, the largest sample size and the highest rates of AUD. This is because the restrictions added to the unemployment and social assistance cohorts resulted in reduced rates of AUD. The income cohort is the oldest and has the highest rates of AUD. Using individuals included in all four samples, we examined correlations between our four outcomes. Associations of early retirement, unemployment and social assistance were modest and positive in both sexes, largely from +0.10 to +0.25. All three of these outcomes were modestly and negatively associated with income at age 50, with correlations ranging, across sexes, from -0.10 to -0.25. --- Results of Cox proportional hazard and regression models We fitted three models for the prediction of early retirement, unemployment, social assistance, and income . In model 1, we examined the raw hazard ratio for our first three outcomes as predicted from a registration for AUD during the follow-up period. In males, an AUD diagnosis most strongly predicted social assistance , followed by early retirement and unemployment . The results were similar in females: social assistance ; early retirement and unemployment . For income at age 50, we used standardized regression and a history of AUD from ages 40-50, which was associated with a decrease in income between a quarter and a fifth of a S.D. in both males and females . In model 2, we add four covariates to the model: age, parental education, neighborhood social deprivation, and prior externalizing behaviors. These potential confounders had the largest impact on the association between AUD and income, the least on social assistance, and modest effects on early retirement and unemployment. Model 3 is identical to model 2 with the addition of a dummy variable for prior history of AUD before the follow-up period for early retirement, unemployment and social assistance, and before age 40 for income. The results of this model determine the degree to which the prediction of these psychosocial outcome variables resulted from the actual occurrence of AUD within the follow-up period, v. AUD registrations prior to this time. In each case, the occurrence of AUD during the follow-up was more predictive than a prior history, but prior history of AUD was also independently associated with the psychosocial outcome. --- Co-relative analyses Our co-relative analyses examined the raw HRs, i.e. model 1 above. The association between AUD and early retirement attenuated substantially in both males and females in the expected order, with HRs highest in the general population and declining in discordant cousins, half-siblings, siblings and MZ twins. In both sexes, the observed HR in MZ twins was nearly 50% of that observed in the general population, consistent with strong effects of familial confounders. When we fit our genetic co-relative model to these results, the AIC improved in both sexes and produced predicted results very similar to those observed. We illustrate these effects for males in Fig. 1. The association between AUD and risk for future social assistance attenuated moderately in males in discordant pairs of relatives with increasing genetic and environmental sharing. The pattern of results was not entirely congruent with genetic expectations in males, and we were unable to obtain sufficient discordant MZ twins to estimate results in either sex. Nonetheless, our genetic model fitted well in males and predicted a HR in MZ twins of about 60% of that observed in the general population. The results in females were difficult to interpret, as the HRs varied widely in the various discordant relative pairs. The genetic model, as expected, fit poorly. While the resulting estimates suggested no familial confounding, it is difficult to be confident in these findings. The association between AUD and risk for unemployment attenuated modestly in males, although again not entirely in the order predicted from genetic theory. As with social assistance, sample size was too small to obtain stable estimates in discordant MZ twin pairs. Nonetheless, our genetic model fitted well and predicted a HR in MZ twins of 80% of that observed in the general population . In females, somewhat more attenuation was observed, and only the discordant cousins produced results out of keeping with prediction. The genetic model fit well and predicted a HR in discordant MZ twins of around 60% of that observed in the general population. Finally, in examining the association between income and risk for AUD, we again could not obtain stable estimates in MZ pairs. However, in the other groups of relatives in males, we saw evidence for rather substantial attenuation of the association that was relatively orderly across relative classes. Our genetic model fitted well and produced a beta estimate in discordant MZ twins only around 30% of that observed in the general population. The results were broadly similar in females, although the estimates in the different classes of relatives were more variable. Again, the genetic co-relative model fitted well and predicted a beta in discordant MZ twins around 40% of that observed in the general population. --- Discussion The goal of this report was to clarify the magnitude and causes of the downward social 'drift' associated with AUD. Using Swedish national registries, we examined the association between AUD and four measures of psychosocial dysfunction: early retirement, unemployment, social assistance, and personal income. We found, using large, longitudinal population-based cohorts, that AUD strongly predicted social assistance and early retirement in both sexes, with HRs ranging from 4.8 to 8.3. The association between AUD and unemployment was more modest . A registration for AUD was associated with between a fifth and a quarter of a S.D. decrease in income at age 50. Our findings are consistent with those of Alm , who documented profound impacts of early drug abuse on mid-life social exclusion -including reduced income, unemployment and receipt of social welfare -in the Stockholm Birth Cohort Study, although we did not see evidence of the gender differences she observed. We then used two complementary methods to clarify the causes of the relationship between AUD and psychosocial dysfunction: adding confounders to our regression models and using an extended co-relative control design. The addition of putative confounders produced variable results across our four outcomes. The strongest attenuation was seen in the association with income, the least with social assistance , and intermediate effects on early retirement and unemployment. These results suggest that the distribution of causal and confounding influences on the association with AUD likely differs across our outcomes. This may partly be due to the Swedish social welfare context, in that early retirement and unemployment benefits are targeted to people with longterm conditions such as AUD that reduce their participation in social institutions such as work . We also found that history of AUD prior to the follow-up period for our study was independently associated with each of these psychosocial outcomes above and beyond the impact of more proximal registrations for AUD, which speaks to the ongoing impact of AUD throughout adulthood on economic integration and social functioning. Our co-relative analyses also produced variable results. For one of them, social assistance in females, the findings -although suggestive of little to no familial confounding -were very hard to interpret as our genetic model fitted poorly. This was not the case for any of the other models, despite observed results not always fitting perfectly with expectations. Congruent with the multiple regression results, we saw the strongest evidence for familial confounding with income. The risk for early retirement in discordant close relatives, especially MZ twins, were also considerably attenuated. For social assistance and unemployment, the attenuation present for both sexes was more modest in magnitude. These results argue against two extreme hypotheses -that the association between AUD and subsequent social dysfunction is entirely the result of causal effects or arises solely from confounding factors. Rather, our findings suggest a more nuanced picture -that the associations observed at the population level arise, to varying extents, from at least two distinct processes. Our results are consistent with the hypothesis that AUD has a causal impact on the risk for early retirement, unemployment, low personal income, and necessity of social assistance, thus providing strong support for the drift hypothesis. Evidence in favor of this hypothesis includes substantial associations between AUD and the social status outcomes after addition of key confounding variables to our multiple regression, including AUD prior to the study period . Even more powerfully, in MZ twins discordant for AUD, the affected twin had significantly higher risks for early retirement, unemployment and social assistance, as well as lower income, than the unaffected twin. It is notable that these findings emerged even in the Swedish context, with the strong tradition of publicly funded mental health and substance abuse treatment that emphasizes care for socially marginalized groups . In the Swedish system, social assistance and other forms of social welfare support are considered a part of treatment for AUD, with many people passing through the medical portion of treatment into the social welfare sector for the remainder of the 'rehabilitation' process, which is dedicated to helping drinkers get back into the workforce and fulfill family and other social roles . Despite this comprehensive treatment approach, there still were significant differences in long-term income and workforce participation for patients with AUD, which suggest that, in addition to temporary social welfare and income support, additional services are needed to help facilitate the integration of persons with AUD into society after medical treatment . We also note that our income analysis examined earnings at age 50, which suggests interventions targeted to people who develop AUD in early and middle-adulthood may be particularly beneficial for improving social integration. In other policy contexts, such as the United States, ancillary support services are warranted to address the long-term negative impacts of AUD that are not addressed by traditional inpatient or outpatient treatment for AUD. Our findings also argue that a portion of the population association between AUD and our measures of social dysfunction is not causal but rather due to confounders. Our evidence for this is a clear diminution in the observed association when key confounders were added to our regression analyses and when the association was observed in discordant pairs of relatives of increasing genetic and environmental proximity. These findings parallel those of McVicar and colleagues , who observed high levels of confounding of the relationships between substance abuse and homelessness in a longitudinal study of Australians at high risk for homelessness. Thus, our results offer a strong case for the role of both familial/genetic and social factors in the association between AUD and social dysfunction. --- Limitations These results should be interpreted in the context of two potentially important methodological limitations. First, these results are specific to Sweden which has a social system relatively different from that found in the United States and a number of European countries. Furthermore, among European countries, Sweden shares with Finland and Russia a relatively distinctive drinking pattern characterized by intoxication-oriented drinking with large quantities often consumed per occasion . The degree to which our findings would extrapolate to other countries remains to be seen. Second, we detected subjects with AUD from medical, legal and pharmacy records. This method has the major advantage of not requiring respondent cooperation or accurate recall and reporting. However, it cannot be expected to entirely replicate findings that would emerge from an interview-based epidemiological survey. By that standard, it is certain that our approach would produce both false-negative and false-positive diagnoses. Given that the population prevalence of AUD in this sample is lower than estimates from epidemiologic surveys including one from nearby Norway , false-negative diagnoses are likely more common than false-positive ones. Additional survey studies in Sweden also suggest that -as in other countries with voluntary treatment for alcohol and drug use disorders -there is a subgroup of heavy drinkers who may never enter treatment despite significant alcohol-related problems . Compared to those identified in epidemiologic surveys, the cases of AUD that we studied are likely to be more severe. The best available validation for our definition of illness is the high rates of concordance for registration observed across our different ascertainment methods . --- Conclusions In a Swedish national sample, AUD registration robustly predicted a range of measures of psychosocial dysfunction. Using the methods of multiple regression with specified confounders and co-relative analyses, our results suggested that the bulk of these associations are likely causal and reflect a negative effect of AUD on social and economic functioning. However, both methods also show that an appreciable proportion of these associations arise from confounding variables which both increase risk for AUD and decrease social and economic competence. Unless these influences are corrected for, investigators are at risk for overestimating the impact of AUD on psychosocial functioning. The estimated hazard ratio for early retirement in males as a function of registration for alcohol use disorder in the general population and in discordant cousins, half-siblings, full-siblings and monozygotic twins. For the method of estimation, see the methods section. The relatively large decline in the association with increasing closeness of relatives suggests substantial familial confounding of the association. The estimated hazard ratio for unemployment in males as a function of registration for alcohol use disorder in the general population and in discordant cousins, half-siblings, full-siblings and monozygotic twins. For the method of estimation, see the methods section. The small decline in the association with increasing closeness of relatives suggests only modest familial confounding of the association. --- Supplementary Material Refer to Web version on PubMed Central for supplementary material. ---

Background-Although alcohol use disorder (AUD) is associated with future risk for psychosocial dysfunction, the degree to which this arises from a direct causal effect of AUD on functioning v. from correlated risk factors (also known as confounders) is less clearly established. Method-AUD was assessed from Swedish medical, criminal and pharmacy registries. In a large general population cohort, using Cox proportional hazard and regression models, we predicted from the onset of AUD four outcomes: early retirement, unemployment, social assistance, and individual income. We then examined the degree to which these associations were attenuated by relevant confounders as well as by the use of discordant cousin, half-sibling, full-sibling, and monozygotic twin pairs. Results-In males, AUD most strongly predicted social assistance [hazard ratio (HR) 8.27, 95% confidence interval (CI) 7.96-8.59], followed by early retirement (HR 5.63,) and unemployment (HR 2.75,. For income at age 50, AUD was associated with a decrease in income of 0.24 S.D.s (95% CI -0.25 to -0.23). Results were similar in females. Modest to moderate attenuation of these associations was seen in both sexes after the addition of relevant covariates. These associations were reduced but remained robust in discordant co-relative pairs, including monozygotic twins. Conclusions-Our results suggest that AUD has a causal impact on a range of measures reflective of psychosocial dysfunction. These findings provide strong support for the drift *

INTRODUCTION Students on courses of study leading to professional nurse registration are required to spend up to 50% of their time within practice gaining direct experience with the client group they have chosen as the focus for their future work , 2005). Traditionally the placement experience has been characterised by an emphasis on allocating students to service settings where they can be directed in their learning by suitably qualified staff. This meets the requirement as laid out by the NMC that students should be able 'to learn with, and from, other health and social care professions ' . More recently the placement learning experience has been expanded to include what has come to be known as the 'hub and spoke' model . In brief, this arrangement places the student in a location designated as the 'hub' which is where they will receive the bulk of their formal and regulatory input from an appropriately qualified practitioner. This area will have sufficient learning opportunities to meet the outcomes expected for that part of their training. There will also be one or more 'spoke' placements, physically remote from the hub, which the student will attend on a pre-planned basis in order to gain more experience of other client groups, to learn other related skills or to observe relevant procedures not routinely available at the hub. By operating across two or more areas the student will then become aware of the realities of inter-professional working. This model demands flexibility from placement providers and students but is reported on favourably by several commentators . For students intending to work with people with intellectual disability this model of learning opens up many possibilities. According to Emerson and Hatton it is the sub group of individuals with more profound disability and impairment who are likely to be looked after in specialist accommodation while the majority of individuals with intellectual disability live with their parents . It is this demographic fact that prompted us to consider utilising families as a potential practice learning experience. We have reported on this elsewhere, with a focus on how students on dedicated intellectual disability qualifying programmes of study experienced the family placement . But in what follows we explore the family placement from the perspective of the parent/carers. The locus for the care of individuals categorised as living with intellectual disability has been closely connected to those professionals equipped to deliver that care since both groups were first conceptualised . From the initial inception of the profession in the early years of the twentieth century, this meant in effect that much of that care took place within segregated settings . This period of institutionalisation reached a peak in the 1950s and 60s . Since then, there has been a move towards a more individual response to disability . When coupled with reaction to more recent events where poor care has been exposed , 2008;Heslop et al, 2014) the need for contemporary intellectual disability professionals to work alongside individuals and families, to secure fairer access to health services, seems clear. Emerson et al highlight the difficulty in obtaining precise numbers when attempting to calculate sub-sections of the intellectual disability population . But we can extrapolate from what is known to suggest that most children and young people with intellectual disability live in the family home, while there are a substantial number of adults with intellectual disability who also remain at home with surviving parents. This much was confirmed by other studies and by our own experiences of setting up the family placement scheme. Dyson worked with families with a child with intellectual disability and from this she warned that 'the paucity of research warrants further study of the family ' . The exposure our students receive on the family placement scheme should make them more sensitive to this deficit in knowledge. We anticipate that their future practice will therefore shape both care delivery and research. Taggart et al offer a clue about the reasons behind this apparent lack of research when they note that family dynamics play a part here. They say 'Limited research has been undertaken on this topic because until recently, people with intellectual disability usually pre deceased their parents . Their study on the support needs of older carers identified a mainly female population who exhibited similar problems and concerns to the ones our own participants discussed. Chadwick et al also looked at the support needs of families. Here a main finding was that the families who took part in the study felt they didn't get enough help from statutory services. They spoke of having to fight to secure assistance and some even felt reluctant about making an fuss for fear of the service being withdrawn . Walker and Ward extend this line of enquiry when they argue for more research around the family due to demographic factors, which means that there is now and will soon be even more need to accommodate the demands that ageing of carers and cared for will place on health and social care services. More recently Ryan et al conducted a literature review which examined family life with an ageing individual with intellectual disability. This domestic situation leads to what the authors call a 'mutually dependent relationship ' . It is apparent then from the literature that there is value in making the family a focus for enquiry. By developing the family as a short practice placement experience for our students we may be able to forestall some of the problems that are being reported as our students take the lessons they learn into their future practice. The involvement of families also recognises the value users of services can bring to teaching, learning and research . --- AIMS AND OBJECTIVES Our current project then aimed to uncover the views and experiences of the families who agreed to offer support to a student nurse within the family setting. This support could range from speaking to students within the university setting to inviting a student to spend some time as a guest of the family where they could begin to gain some understanding of the lived experience of caring for child who has an intellectual disability. Family carers were keen to contribute to the education of future professionals and also wanted them to know 'what life was really like' for them. Within this our objectives were to check on the scheme's suitability as a vehicle by which to offer placement experience to our students, and to confirm that the families hosting the placement were comfortable in that specific role and also more generally as being part of the educational process. Methodologically a 'placement' whereby an individual is located with a host family might appear, prima facie, to be an opportunity for an anthropological study or even an ethno-methodological approach . Here though our data generation and analysis occurred after the event and so resembles a modified ethnography. This 'practice-near research' model is defined thus -'Practice-near inquiry might be defined as the use of experience-near methods for practicebased or practice relevant research. Such methods include ethnography, some forms of indepth qualitative interviewing and observation, and the use of images and other sensory data in research ' Froggett and Briggs This description feels very close to the experience we wanted to gain access to -that which occurred when the students were working in the family home. As such we felt it appropriate to our own circumstances and to those of the families we interviewed. --- PROCESS, PARTICIPANTS AND PROCEDURE We secured ethical approval for the study via the School of Health and Life Sciences Research Ethics Committee, [insert university name]. The family placement scheme is run as part of a 'Hub and Spoke' model within the nursing programme. As part of the spoke practice learning opportunity students may spend some time with a family and thus become part of the Family Placement Scheme. The length of time spent with the family varies between the needs of the family and needs of the student but may range from a one day visit to up to 5 days over a 6 week period. The student meets with the family well in advance to plan a mutually agreeable timetable of when it is appropriate for the student to visit the family home. Depending on the family this may be in the morning to help with getting the child ready or later in the day to be available to help with family outings. Some families are happy for the student to attend the full day from 9.00 -5.00 but this very much dependent on the local circumstances. Students are encouraged to be sensitive to the needs of the family when planning their attendance. Fourteen parents provided family placements to second-year nurse students over two academic years . All parents were invited to take part in individual qualitative interviews by a researcher within three months of the first placement they provided being completed . Seven of the parents chose to take part in the interviews. The interviews were conducted in the parents' homes by the researcher on dates and times which were mutually convenient. The interviews were recorded on a digital recorder, and then transcribed. All identifiable information was changed during transcription, thus pseudonyms were used for all participants who took part. Transcribed qualitative interview data were subject to content analysis and then arranged according to the following four themes : 1. Parents' description of their caring role. 2. Parents' perceived value of the family placement to the nurse student, themselves as a carer, and to their child with a learning disability. 3. Parents' views and experiences of the role of carers in nurse education. --- Parents' views and experiences of learning disability nursing. As this was a broadly descriptive study, these themes were derived from the interview schedule as specific areas of enquiry. A copy of the interview schedule is directly available via the authors. Subsequent themes which emerged from these interviews were: worry, depression and isolation; holiday/leisure time and things not going to plan; giving up and returning to work after becoming a parent of a child with learning disability; the impact of adverse life events on family support; parents' having someone to talk to; having new/extra company in the house for child with intellectual disability; placements offering nurse students a different experience/perspective; and parents' love and affection for their children with an intellectual disability. Analysis was first conducted separately by two authors , independently of each other, with the final emergent themes agreed upon after they were scrutinised by the other . --- FINDINGS Parent Characteristics The characteristics of the seven parents who took part in the qualitative interviews are presented in table 1. All of the parents were mothers, white/native to Scotland and with an average age of 49 years. Five of the mothers cared for a child with intellectual disability , whilst two cared for an adult with intellectual disability . ******Insert table 1 about here****** Here we present the findings from the study, in order of the four main themes as they were elicited in response to the interview guide. --- Parent-Carer Role When compiling our interview guide we wanted parents to describe their caring role before we enquired about the potential value of the family placement scheme, to get a sense of what the nurse students would gain exposure to through these placements. All seven parents described their daily demands and routines of caring, and related issues, which echo some of the issues we found in the literature : --- In the morning I get [my daughter] up sharp. [My daughter] gets showered at night time…We get hoisted up in the morning, breakfast, the school bus comes, [my daughter] goes to school…during the night I've got to turn [my daughter]…so I don't get a full night's sleep. I have to get up four, five times during the night to turn her…so maybe I'll catch a wee hour [sleep] on the settee after the school bus comes' . --- 'In a typical morning when we're getting ready for school, [my son] takes an hour and a quarter to an hour and a half, all him in the morning to get ready. And that's not [my husband or I] having a shower or breakfast or anything. It's just when you look at it like that, when you're doing that in the morning, and it's kind of similar in the evening…when you add it all up, if it wasn't for school, we'd probably spend 5 or 6 hours just changing, dressing, washing, feeding' . 'Your life is consumed with appointments, with telephone calls' . In addition to these descriptions, three parents described their worries and/or their feelings of depression or isolation: 'There are mornings where I can't get up, for a while, off the couch, because I've sent [my son] to school and I'm maybe reflecting or worrying. And when he's not well for quite a long period, that feeling in me can go on, and that's when my family starts to say, my mum will always say, are you sure you're not depressed?...I've referred myself to a place called [name of counselling service]' . '[My daughter] can't cope with…going to soft play…she can't cope with…going to the park, things like that, although she's got a lot better…So that was really isolating for me' . Four parents also talked about their holidays/leisure time and things not always going to plan: '[My eldest daughter]…passed away. She was only forty as well…I just assumed my [eldest] daughter was the one who was going to take care of her because she always did say that, and now unfortunately that's not going to happen…We need a break. [My husband] has retired. I think he feels everything's been taken away from him. And all that happening with my eldest daughter… His whole life has changed' . ' --- Value of Family Placements It is against this backdrop that we can situate the responses to our questions on the value of the family placement. We asked the participants about how they felt the placement worked for them, for their child, and for the student. Susan, Karen and Kelly all spoke of the benefit they derived from having someone to talk to. It was Kelly who emphasised this when she said: I got a lot out of it because I was feeling quite alone at the time…There was a lot of chatting, which is good. I really enjoyed having [the nurse student] here, in the home…So it was good for me' . Likewise Karen also appreciated the benefits of having another person to talk to. She told us: 'I felt easy with [the nurse student]…she was easy to talk to. It wasn't awkward. I needed to talk to her, plenty of chat' . In terms of the value of the family placements for their children with an intellectual disability, having someone new in the house, and having 'extra company' , was mentioned by three parents: 'I think [my daughter] enjoyed her company…Well, she enjoys company, so another person in the house was quite nice for her' . Two of the parents also mentioned the appropriateness of the particular nurse student for their child with intellectual disability, both in terms of gender and being of a similar age and so being more likely to have shared interests: 'I had specifically asked for a male, because I thought that would help with [my son's] selfawareness, confidence and all that. [My son] really liked showing off and having a man in the house' . --- 'Yes, [my daughter and the nurse student] went to see [famous pop star in concert]' . Four of the seven parents felt that the different experience/perspective family placements offered was the most valuable learning outcome for nurse students. Emma for example, suggested that for the student '…it's brilliant to get a whole different perspective of how families live'. Emma also appreciated that this could work for her benefit too. She told us 'I --- think the experience really, really helped me, to let me know that not everybody sees [my daughter] the way l see her… sometimes as a parent you only see what difficulties and challenges are for the child' Karen felt that family placements help students to appreciate the demands of caring: 'Maybe seeing the stress families are under'. A further two parents felt that family placements provide informal opportunity for nurse students to ask questions about their parent carer role: '[The nurse student] was asking me quite a lot of questions. I felt that because she was with me one-to-one she was able to ask more' . It was apparent too that the contribution of the students could have practical as well as emotional and psychological benefit. Joan described a situation where the knowledge of available services the student brought with her led to a real improvement in her circumstances. --- '[The student] actually found out a lot of information about a wee swimming club, and different things, so they are bringing in information…I didn't have this and I didn't have that, and [the student] said, you should [contact] your community occupational therapist…I got in touch [with Occupational Therapy] and I got a tracking hoist in…a new up and down bed…and…a new toilet seat. If [the nurse student] hadn't pointed that out…I would have carried on the way I was carrying on…' . --- Carer Involvement in Nurse Education We then talked about how the participants saw their own involvement in student nurse education. All seven parents said they thought it was important for colleges and universities to involve or include family carers of people with intellectual disability in intellectual disability nurse education. Three of the parents had participated in student training before. They described their experiences as being both nerve-wracking but enjoyable: 'It was fab…I was petrified…I am not a hot shot with a university degree. I don't speak the way university people speak, but I just hope [nurse students] take me as a mum, as a carer of a person with a disability. So if I can help that way I [do], it's not a problem' . Some saw it more as an opportunity to share their experience of caring for their child by turning their insights into potential knowledge. Susan spoke of her time spent with students on a child nursing degree programme: 'One [of the times] was giving a presentation, and the other was just talking to a small tutorial group about what it's like to be a parent-carer…It was personal. It's challenging because it's been a really difficult time the last few years, but I feel that's kind of the silver lining, if I can pass on something to other professionals that will give them insight, and therefore be better at their jobs, then it's kind of worthwhile…something positive coming out of it' . In terms of increasing their involvement in intellectual disability nurse education in the future, four parents liked the idea of open days at the university, for parents, their children with intellectual disabilities, and nurse students to meet up and share their experiences and information: --- 'I really like the idea of open days. [It] would be brilliant to go on an open day. And it would be a meeting point for other parents, other children' . '…It's really important; maybe as an in introduction before [family placements] start, to make sure the nurse and the mother or father, the family are comfortable' . Of the four parents who had no previous experience of being involved in student education, three said they would be happy to become more involved in the future, to share their experiences. Karen however, said 'I'm not ready to talk about things or anything like that'. --- Parents' Views and Experiences of Intellectual Disability Nursing Our final question asked the participants to reflect on their views and experiences of intellectual disability nursing. Perhaps surprisingly four of the parents had no prior experience of a nurse being involved in the care/support of their child. There are local reasons for this. Children with intellectual disability in this geographical region of Scotland are much more likely to receive health care/support via paediatric services, rather than community-based intellectual disability health care teams. In Fran's case, a second, condition-specific factor was involved : 'I hadn't heard of them before. [Family support organisation who helped organise the family placement] said to me learning and disability nursing…The epilepsy nurse is at [paediatric hospital] and we just go and see her' . --- Parents' Love and Affection Throughout the interviews all parents described their love for their children with an intellectual disability, and the affection between them: '…it is stressful. But at the same time I wouldn't be without her. I couldn't be without her. I really couldn't' . 'There's a lot of hard work. There's a lot of good fun…Last night she came back from a party and she was full of kisses and cuddles so, as I say, she's kind of full of happy nonsense most of the time which is fun' . --- DISCUSSION The main reason for conducting this study was to learn about parent-carer involvement in intellectual disability nursing education. This was realised principally through their involvement in the family placement scheme. From this our participants were able to share their experiences as carers with nurse students. The interviews we conducted with parentcarers of children with intellectual disability provide us with insight into the actual experiences nurse students were learning about whilst on family placement; from detailed descriptions of the daily demands of caring, to gaining understanding of the wider aspects of family holidays and the impact of adverse life events on family support. And in the detail provided we find echoes of the divergence that characterises practice in intellectual disability settings. The reciprocal nature of family placements was also demonstrated, in that nurse students appeared to benefit from opportunity to ask questions on a one-to-one, informal basis, whereas parents also seemed to benefit from having someone to talk to about their caring role, gaining positive experience of seeing their child from someone else's perspective, and nurse student's knowledge of available services leading to improvement in care. Towards the end of the last century the idea of promoting a shared research agenda in this field was given impetus by commentators such as Zarb , Charlton , Kiernan and Rodgers, . Since then user and carer involvement in research, education and practice fields has become standard . For the present study this means that what might have once appeared as challenging or radical is now more readily acceptable, both in the academy and in practice and, as we hope we have demonstrated here, in the family home. The parents valued the opportunity for nurse students to learn from their experience about what it is really like to care for a child with intellectual disability at home, and from the parents' perspectives, this was viewed as the most valuable learning outcome for nurse students on family placements. All parents felt that it was important for universities and colleges to involve family carers in nurse education. The majority spoke positively about they themselves being involved in nurse education more formally , as well as providing family placements. One parent however, did not wish to be more involved on a formal basis due to '[not being] ready to talk about things'. This serves as an important reminder that caring for a relative or loved one at home is a highly personal experience, and that we must demonstrate sensitivity and respectfulness at all times. There are lessons here for both practice education and research. The final theme to emerge from these interviews centres around the very positive aspects of caring, that were apparent in the interviews. We felt this was particularly important to emphasise as caring for a child with a disability can often be portrayed as a burden. In their literature review Ali et al looked at the concept of stigma and how this was shared by family members who endured the social isolation ascribed to their children by proxy. Elsewhere Irazabal et al calculated that any 'disability in participation in society and personal care are the main areas that contribute to higher family burden' . These descriptions of stigma and burden would certainly include the families in our study. But they showed resilience in their attitude to caring, in that family holidays do not always go to plan they think it's important to go on holiday anyway, and having to give up work due to caring but returning to or commencing work later on. All seven parents demonstrated love and affection for their children throughout the interviews, and this too, is important learning for nurse students. There is some evidence that the only negative connotations associated with caring for a child with a disability are being recognised and challenged, whereby Blacher and Baker prefer the term impact to burden. Linguistics aside we felt it very important that the students were able to experience this positive sense of love and affection and parent/carer resilience for themselves, and also to report on it here. All of the parents who took part in this study had recently provided family placements to intellectual disability nursing students, yet of the seven parents who also completed interviews, four have no experience of an intellectual disability nurse being involved in the care/support of their child with intellectual disability; thus were not able to comment on their experiences of intellectual nursing in practice. The placements themselves brought added value as the parents liked making a contribution to the professional development of these nurse students, and appreciated the students' interest and/or enjoyment in their child with intellectual disability. As mentioned earlier, these interviews build on our understanding of the value of family placements from both the parents' perspectives and the nurse students' , and once again the reciprocal nature and benefit of family placements are emphasised. Both the parents in this study, and the nurse students in our earlier study who participated in the placements these parents provided , stressed realising the daily demands of caring on family life, and the development of communication skills with family carers as main learning outcomes for nurse students; indeed in this present study, opportunity to talk about caring with each other is evidenced as having value. --- Implications for Practice Health and social care professionals in training/education must spend around 50% of their time 'on placement' in order to meet the criteria as laid out by regulatory bodies . For those who want to work with people with intellectual disability the location and design of placement learning opportunities has changed. Today nurse education, in this field certainly, is guided more by principles of inclusion so that a partnership approach is favoured and this is reflected and supported by policy . In addition the Nursing and Midwifery Council states, in point 15 of their guidance document for student nurses, that they should 'Work in partnership with people, their families and carers' . The benefits here are that from a purely educational perspective the standpoint epistemology that the service user/patient brings to the situation can only ever reduce the theory/practice gap . In intellectual disability settings the long-established principle of inclusion means that the learner can be placed in direct contact with the source of knowledge via the family placement. The arrangement needs to be regulated by the faculty but the unmitigated experience of working in such close proximity can only ever be achieved in situ. And from a purely practical perspective, the placement ought to be defined by its target audience -people with intellectual disability and their families. We feel that the feedback from the participants in which they identify sharing and offering their own unique perspective as key to the success of the venture fully vindicates the use of the placement. --- Strengths and Limitations The strength of this study lies in the modified ethnographic approach. The 'practice-near research' gave us intimate access to the lives of the participants. This approach is favoured because by 'Positioning research close to practice creates opportunities for a greater complexity of experience to be understood by practitioners, across a wide number of fields. These fields range from considering the impact of structural disadvantage facing service users and their families, through to capturing inner world, emotional experiences which impact upon people's lives' . By allowing the parents/carers to describe in their own words the daily trials of caring we were better able to then move on to elicit information about their views and experiences of the family placement scheme. Here we adopted a sympathetic stance via the interview schedule and so were able to ask openended questions which prompted a detailed account of experiences of caring and how this played out in practice when students became involved in the household. A limitation is that only seven, or fifty per cent of the parent-carers who provided family placements during the assessment period, chose to take part; thus findings are not representative of all parent-carers who participated in the scheme. Nor are we able to extend any claim that what we found here might be replicated elsewhere. More work needs to be done, to involve parent-carers in research as well as increasing their participation in family placements and nurse education. All seven participants were mothers . Five of the seven had a male partner, but their partners did not contribute to the interview, so the voices of male family carers/fathers were not heard. In addition, five were mothers of children with an intellectual disability, and as such, had limited or no experience of intellectual disability nursing in the care of their child. Future practice and research should include more family carers of adults with an intellectual disability, who receive care and support from intellectual disability nurses. --- CONCLUSIONS The role of the nurse delivering care to people with intellectual disability has evolved considerably over the past 40 years from operating within a mainly institutional system to one of community support within the least restrictive environment . The hub and spoke model of training develops this further and allows opportunity to work more closely with family carers of people with intellectual disability, to enhance learning; and there will always be families who need varying degrees of assistance to care for a child with intellectual disability. We believe this small scale example demonstrates that by aligning the educational needs of nurse students with the domestic arrangements of families who care for a child with intellectual disability, it is possible to provide a harmonious setting that is of mutual benefit to all parties.

The aim of this research was to learn about the value of family placements, as experiential learning opportunities, from the perspectives and experiences of parent-carers who provide them to nurse students via a Scottish university Family Placement Scheme.Qualitative interviews were conducted with seven (50%) parent-carers who provided at least one family placement over two academic years (2012/2013 and 2013/2014). Broadly descriptive data was analysed, organised into themes and subject to content analysis: parents' descriptions of their caring role; their perceived value of family placements; and their views and experiences of carer participation in nurse education, and intellectual disability nursing.Family placements were perceived to be mutually beneficial to nurse students and families of children and adults with an intellectual disability, and provide for example, opportunity to develop communication. Detailed description of the daily and wider aspects of caring was provided, offering insight into the actual practical learning experiences of nurse students on these placements.This hub and spoke model of learning provides unique opportunity for nurse students to learn what it is really like for families to care for a relative with an intellectual disability at home, and to develop their practice skills for working in partnership with family carers.

A vignette: To return or not to return? It was May 8th, 2018, and I was flying from Istanbul to Tehran when then-President Trump was anticipated to make an announcement regarding his decision on whether the United States remain in or withdraw from the Iran nuclear deal. This was major news for the Iranian people as the devastating economic consequences of the US withdrawal from the deal were crystal clear. It was frustrating to be kilometers above the ground with no Internet connection when such a major announcement was scheduled. As someone who had emigrated from Iran to Canada a few years earlier, I was going back to Iran to visit my family and conduct research on a question that had been perplexing me: why do Iranian immigrants return to Iran despite its deteriorating living conditions? On the plane, most passengers were Iranians, and I couldn't help but wonder if any of them were return migrants. I overheard a group of young Iranians in the front row chatting cheerfully about their trip to Türkiye, a visa-free neighboring country that many Iranians desire to visit, where they can escape the strict dress code that the Iranian regime enforces and freely enjoy their time at the beaches and nightclubs. As the pilot instructed, I turned my phone off before the takeoff, eagerly waiting for landing to connect to the Internet and find out what would happen with the Iran nuclear deal. Once we reached the airspace above Tehran, however, some passengers turned on their phones and connected to the Internet to check the news. A young woman became the first reporter: "He pulled out of it, damn!" Another passenger confirmed her report, and a distressed voice --- Introduction Scholars of return migration have traditionally focused on economic cost-benefit analyses of return. The economic model, which is informed by the rational choice theory, views the movement of individuals in terms of their pursuit of a more promising future based on utility maximization . In this context, return migration is conceptualized as a rational decision-making process undertaken by individuals, often with the aim of maximizing their financial gains. Accordingly, individuals choose to return to their home country after acquiring valuable human and economic capital, which can be effectively leveraged within the context of their homeland. This understanding of return, however, does not fully explain the complex dynamics that characterize North-South return migration, particularly the return migration cases to an economically challenging context. As such, it remains unclear why some migrants, having undergone the often costly and time-consuming process of immigration and having resided in prosperous countries in the Global North, decide to return to their home countries, such as Iran, in the Global South with challenging social, political, and economic circumstances. As a multi-faceted phenomenon, North-South return migration requires an investigation of various aspects of migrant lives, which includes not only economic aspects but also, and notably, family relations and ties. Moreover, a predominant focus in the study of return migration has been on the statecentric and top-down approach, which involves analyzing the return process within the context of international paradigms . While this approach has generated valuable knowledge about the nuanced nature of return migration, it does not provide a complete understanding of this complex phenomenon. Adopting a bottom-up approach in the investigation and analysis of return migration, on the other hand, holds the potential to shed light on the complexities and nuances that underpin return migration movements, particularly in the context of seemingly puzzling North-South return migration cases. By examining the motivations, experiences, and perceptions of North-South return migrants, a bottom-up approach can offer an in-depth comprehension of the various factors at play in the decision-making processes and the realities faced upon return. This approach recognizes the agency of return migrants as active social actors and considers their unique perspectives, social networks, and personal circumstances that shape their return migration trajectories. Consequently, it enables researchers to gain a more comprehensive understanding of the dynamics, challenges, and opportunities associated with North-South return migration, contributing to a more holistic knowledge base in migration studies. Drawing on empirical data from my research on Iranian return migrants, this article presents a nuanced perspective on North-South return migration by examining the firsthand experiences of return migrants. It delves into their personal accounts, shedding light on their individual migration trajectories and the personal meanings they attribute to their return migration journey. I assert that the decision-making processes of return migrants are more complex and culturally diverse to be fully explained by economic models based on cost-benefit analyses and a top-down approach. To capture such complexity and diversity, this article adopts a bottom-up approach and places the narratives, perspectives, and understandings of migrants at its center. Hence, I ask the following questions: How do return migrants perceive and articulate what motivated and facilitated their return from a prosperous Global North country to the challenging living conditions of their home country in the Global South? How do they explain the role of their families in the homeland in shaping their return migration trajectory? Informed by social network theory, this article highlights the agency exhibited by North-South return migrants and underscores the central role of transnational relationships, particularly family ties, in shaping migrants' decision to return, even when confronted with challenging living conditions in their homeland. Moreover, this study not only emphasizes the significance of home countries in the Global South for migrants but also aligns itself with the principles of critical geopolitics. Informed by Edward Said's influential concept of Orientalism , it offers a critique of the prevailing Orientalist narrative that portrays Global South countries as subordinate to their Global North counterparts. --- The economic models of return migration Migration scholars have studied return migration through various theoretical approaches. Some of these theories are primarily based on economic cost-benefit analyses influenced by the push and pull factors of the global market and the neoliberal framework. For example, the neoclassical economics theory considers the anticipated higher earnings in the host countries compared to the home countries as well as the achievement of permanent settlement and family reunification in the host countries . As such, return migration is seen as a result of migrants' failure to achieve the expected advantages abroad . This theory adopts a deterministic approach, focuses on the macro-level economic factors such as income differences between home and host countries, and overlooks the diverse experiences of individual return migrants . On the other hand, the theory of new economics of labour migration understands return as a phenomenon dependent on the accumulation of savings and the achievement of migrants' objectives in host societies . Informed by rational choice theory, this framework views return migration as a rational decision made by migrants based on a cost-benefit analysis and, hence, a sign of an economically successful migration experience . This theory, however, oversimplifies the complex decision-making processes that return migrants undergo and overlooks the non-economic factors that influence migrants' decisions to return, including the role of migrants' social, cultural, and emotional ties to their homelands. In these theories, return migration is oversimplified as a binary assessment of either failure or success of the initial migration. However, the success and failure defined in these theories ignore the social context in which return occurs and may not match the migrants' perception of success and failure in their migration trajectory. As these theories often adopt a top-down approach, they overlook migrants' own understanding and perception of their return migration trajectory. An inquiry may arise regarding whether return migrants understand their return migration trajectory within the framework of a dichotomous narrative of either success or failure. The dichotomous approach to the understanding of return migration also leads to a focus on the migrant's experiences overseas as the sole cause for their decision to return, disregarding the multifaceted and complex nature of the return migration experience shaped by migrants' agency and their transnational social connections . Moreover, from the perspective of these theories, return migration from a prosperous country in the Global North to a home country in the Global South with challenging socioeconomic and political conditions may appear atypical and perplexing. Migrants dwell within a transnational social field and maintain social, cultural, political, and economic connections that transcend national boundaries, particularly in today's globalized world where technological advancements in communication and transportation have made it possible for individuals, families, and communities to stay in touch despite often vast geographical distances. Migrant lives are now deeply embedded in a cross-border network of relationships, influencing their decisions about returning to their home country. While acknowledging that the socioeconomic conditions in the host society can play a decisive role in the decision to return , this study places particular emphasis on the impact of families who stay in the home country. These stay-behind families are pivotal in shaping return migration trajectories. --- Social network theory and family ties in return migration Among the theories of return migration, social network theory draws specific attention to strong cross-border ties in the decision-making processes of migrants . According to this theory, social ties and relationships play a pivotal role in return migration process. It emphasizes that social connections, such as family ties, influence migrants' decision to return and their experiences and outcomes. Social networks can provide valuable information, emotional support, and material resources to migrants in their emigration, settlement, and return migration processes. Among various social networks, connections to family members in the home country influence various aspects of the decision to return. The influence of family ties in return migration can vary depending on cultural norms and individual circumstances. Among various types of social networks, this study focuses on the role of family ties. In DaVanzo's term, family ties serve as "location-specific capital," which implies that their emotional and practical support is linked to a particular location and cannot be easily transferred to a new location . Family members in the home country can function as a safety net for return migrants and, thus, facilitate the process of return migration. Such social connections may encourage return and make it possible by serving as sources of information, emotional support, and practical assistance to help return migrants resettle in their home country . In addition to their role in facilitating return migration by providing support to returning migrants, families can also serve as a motivation for return because family ties may create a sense of duty and responsibility towards family members who have remained in the home country . As such, the function of care as a binding agent that interconnects the lives of family members is intricately linked to the culturally informed sense of obligation and commitment of individual members to family connection and caregiving . As research on social relationships demonstrates, relationships with family members often considerably differ from those with friends, acquaintances, and colleagues because family relationships are inherent and tend to remain essential parts of social networks regardless of geographical distance and passage of time . Therefore, the decision to return to one's home country can be driven by a feeling of duty to family members residing there. Once back in their home country, return migrants can serve as a crucial source of social, emotional, and economic assistance for family members in the home country. Hence, family ties can play a central role in not only motivating return migration but also in promoting social cohesion and support networks in the home country. By integrating relationality into the field of migration studies, social network theory considers that return migration is not merely an individual's personal choice but a decision shaped by the social group to which return migrants belong as well as the social context in which they are situated . Social network theory highlights the notion of "linked lives" , which pertains to the interconnectedness of human lives within social relationships . As such, the migrants' intention to return is not solely shaped by individual rational choice and economic cost-benefit calculations but also -and indeed centrally -by families as a geographically dispersed social group . In these family networks, social norms such as upholding familial responsibility, obligation, and emotional connections are created and maintained, which can influence and motivate return . This point can be seen in an empirical study on the return migration intentions among Moroccan migrants in Europe by de Haas and his associates , who demonstrate that migrants' labor market integration in the host country does not have a significant impact on their return migration decisions, but a sense of attachment and belonging to their home country is positively related to their return migration intentions. --- The puzzle of return migration to Iran Iranians have experienced various social, political, and economic challenges since the 1979 Iranian Revolution. Right after the revolution, the prolonged Iran-Iraq war of 1980 to 1988, coupled with politico-economic sanctions by several countries, most importantly the United States, devastated the economy and left long-lasting, adverse impacts on the country. In recent years, Iran has experienced a rapid economic decline driven by various domestic and international factors. Issues such as drought, widespread corruption, and new sets of economic sanctions have led to the continuous devaluation of the Iranian rial and further devastation of the national economy . Moreover, the establishment of an authoritarian and theocratic regime following the revolution has led to the imposition of socio-political pressures on the Iranian population . These pressures include mandatory dress codes and the suppression of social and political activism deemed "anti-revolutionary" . These restrictive measures, coupled with economic instability, have contributed to the growing desire among Iranians to seek opportunities abroad, primarily in countries in the Global North, including the United States, Canada, the United Kingdom, and Germany . Despite the apparent deteriorating living conditions in the country, however, there are Iranians who, after going through the often time-consuming and resource-intensive process of emigration and after living in countries with stable socioeconomic and political conditions, mainly in the Global North, voluntarily return to Iran. According to the Iran Migration Outlook , in the two years prior to this research, in 2016 and 2017, 6600 Iranian migrants returned to Iran as part of the assisted voluntary return. However, there is a lack of statistics regarding the account of independent voluntary returns to Iran. I contend that the voluntary return of Iranians is a puzzling case because of the seemingly socially, politically, and economically undesirable contexts of return. To understand how return migrants understand the voluntary return migration that brought them back to Iran from a prosperous country in the Global North, this article investigates the ways in which Iranian return migrants perceive, contemplate, and articulate their return migration trajectory and the meanings they attach to their decision to return. Specifically, it examines their narratives about their families in Iran and the role of family ties in shaping their understanding and decisionmaking processes of return. Previous research on return migration to Iran is scarce. The few studies conducted on the case of Iran, similar to general scholarship on return migration, focus mainly on the living conditions of Iranian migrants in the host society and the issue of integration, particularly in the labor market . The role of family ties, while mentioned in these studies, is overshadowed by the economic cost-benefit analysis of return. Moreover, the dichotomous narrative of success and failure in regard to integration and return is prominent in these studies. In this article, however, I attempt to bring the role of family ties to the forefront. I assert that return migration is contextual and needs to be understood in light of the cultural context of the group under study. In the communal culture of Iran, family ties play a foundational role in migrants' decision-making processes. As such, I highlight the importance of family ties in motivating return migration to Iran regardless of the economic cost-benefit calculations. --- Method In this article, I draw on semi-structured, in-depth interviews with eleven Iranian return migrants. The interviews were conducted in the summer of 2018 in Tehran, Iran. I used my social network in Iran and Canada to recruit participants through snowball sampling. The participants consisted of five women and six men ranging from ages 30 to 75. They were skilled migrants from a middle-class background, with at least a bachelor's degree before emigrating from Iran. Their educational background consisted of engineering , education , and architecture . They all had legally emigrated from and legally returned to Iran. I have adopted Erdal's definition of return migration, which characterizes return as "the movement of migrants back to a country of origin, following an absence of at least one year" . Accordingly, the participants resided for at least one year in countries in the Global North, including Australia, Canada, France, Germany, Norway, Sweden, the Netherlands, and the United States, and voluntarily returned to Iran at least one year before the time of the interviews. I met the participants at their places of choice, in cafés, at their homes, or at their workplaces. Interviews were between one to two hours long. I conducted the interviews in the Persian language, and for security concerns raised by the University of Calgary's Ethics Board , I only took notes of the interviews and wrote down quotes that seemed central to the participants' accounts of return. I consulted participants' lived experiences of emigration, immigration, and return migration and paid extensive attention to the ways in which they articulated their return migration experience and their reasons for return. I utilized narrative analysis to interpret and analyze participants' narratives . As such, I examined the content of their accounts to identify themes, meanings, and patterns to better understand how they made sense of their seemingly puzzling return migration trajectory from a prosperous country in the Global North to the adverse living context of their home country. Informed by their narratives, it becomes evident that family ties play a pivotal role in driving their decision to return to Iran. I translated the interview notes and selected quotes from Persian to English. Due to translation, the quotes from these interviews do not represent the verbatim responses of the participants. My positionality as an Iranian immigrant residing in Canada placed me in a distinct and nuanced relationship with my interlocutors, thereby potentially creating mutual comprehension of migration experiences. The fact that I conducted interviews in Iran further deepened my connection to the interviewees, as I shared with them my own ruminations on the prospect of returning. My proficiency in the Persian language, native familiarity with sociopolitical and economic conditions in Iran, and firsthand experience as an immigrant functioned as critical conduits for establishing rapport and engendering trust with the participants. It is worth noting that the purpose of using a small sample size is not to create generalizable claims but rather to generate unique case studies that exemplify the complexity and diversity of a given phenomenon . Hence, as a "small N" qualitative study, this research provides a subjective understanding of return migration and the personal significance that return migrants attribute to their return migration trajectory. --- Navigating challenges in conducting the study As mentioned in the opening vignette, I arrived in Iran to conduct my research on May 8th, 2018, which was the day that the United States withdrew from the Iran nuclear deal, causing a state of anxiety and panic in the country. The withdrawal from the deal meant significant economic and socio-political impacts on the people of Iran. Since the beginning of my data collection, when I told my family and friends about my research on return migration to Iran, I received warnings from them about the sensitivity of the topic, particularly from the perspective of the regime in Iran. My insistence that the research was not about leaving Iran but returning to the country did not seem convincing to anyone. Additionally, conducting research in Iran while affiliating with a Western university could raise suspicion. Warnings from my family and friends were further reinforced by an alarming email from the University of Calgary's Ethics Board a few days after my arrival in Iran. The email cautioned me about the possible risks of being arrested by the Iranian regime due to my dual citizenship in Iran and Canada. The email read: There is currently an arbitrary crackdown by the Iranian government on the Iranians who hold dual citizenship […] I appreciate, though, that this is probably not an ethics-related issue per se, but something for the researcher to be aware of while planning things. Eventually, the warnings convinced me to become more cautious when recruiting participants, so I restricted my selection to individuals within my closer social circle. These warnings also made me opt to take written notes during the interviews instead of recording them. Another challenge I faced while conducting this research in Iran was the regime's censorship of the Internet. Social media platforms like Facebook and Twitter were blocked in Iran, leading many Iranians to resort to instant messaging apps like Telegram to keep connections. Given its widespread use at the time, I planned to use Telegram to recruit and communicate with potential participants. However, the Iranian regime blocked its access just days before my arrival in the country. This made it more difficult for me to access potential participants. Despite the challenges I encountered, I was fortunate to have a reliable social network in Iran that helped me recruit participants who were willing to meet with me and share their return migration stories candidly. --- "Why did you return?": Not a puzzling but a frustrating question When I asked Kian why he returned, his frustration was evident. Kian, a 42-year-old engineer, left Iran after the Iranian Green Movement -a political movement that arose after the 2009 Iranian presidential election and was brutally suppressed. A graduate from a prestigious university in Tehran, he felt he was missing out when seeing his classmates applying to top Western universities not only to continue their education but also because a student visa was often the easiest and cheapest way to emigrate from Iran. Kian told me: "I was a student at an internationally well-known university, and around that time , most of my fellow classmates were talking about immigration and getting student visas from MIT or Harvard. I didn't want to miss out." Kian spent two years completing his graduate studies at a university in the Netherlands, and after his graduation, he decided to return to Iran. As per his request, Kian and I met in a cozy café situated adjacent to the beautifully landscaped Gisha Park, located in the northwestern region of Tehran, on a hot summer day. Though we had been looking forward to chatting in an air-conditioned café, the power went out as soon as we stepped inside. As expected, we began discussing the frequent power outages that Tehranis were experiencing that summer. Kian explained how such outages in big cities like Tehran were utilized by the city to ration power generation and consumption in light of the drought and the limited water volume behind the country's dams. Our conversation soon veered towards the country's economic situation in the aftermath of the US withdrawal from the nuclear deal. When Kian expressed his concerns about the country's economy and its future, I seized the opportunity to pose the question as to why Kian had opted to return to Iran despite expressing concerns regarding the future of the country. He paused for a moment and, with a bitter smile and a softer tone, responded: I keep getting this question! The inquiries about my return range from blunt statements such as 'Are you stupid?' to desperate pleas for an explanation like 'We are desperately trying to leave, and you return?' Frankly, it's frustrating that I am expected to provide a rational and convincing justification for my decision to return. --- While I could try to come up with a list of seemingly rational reasons for my return, none of which, however, would reflect the truth behind my decision. I wish I could simply answer the question with the most honest response: I just came back. Period. Upon their return to Iran from a prosperous country in the Global North, Iranian return migrants often encounter inquiries about why they returned. This question is commonplace and expected, given the perception that leaving Iran for a prosperous country in the Global North represents a "golden opportunity" that no rational person would squander. While the topic of return elicits confusion for non-migrants, it is often a frustrating topic for the return migrants who feel compelled to provide, as an Iranian return migrant noted, "rational" reasons, informed by financial cost-benefit calculations, for their seemingly incomprehensible decision to return to Iran. In 2010, Mahsa, an engineer and mother of two, emigrated from Iran with her husband and children to live in Canada. Like Kian, she saw immigration as a "golden opportunity" to achieve a better life in a prosperous country in the Global North and did not want to miss the chance. She also expressed concern for her children's future and wanted to provide them with "the best opportunities on the planet." However, after two years in Canada, Mahsa and her husband decided to return to Iran. When I asked why she left the perceived "golden opportunity" of living in Canada and returned to Iran along with her family, she, with a frustrated tone, told me: We, Iranians, think the West is heaven, and living there is going to be like living in heaven! Well, let me tell you that it is not! Whatever they have there, we have better of it here in Iran. Mahsa's statement reveals a level of frustration toward the inquiry about her return. Her idealized image of the homeland stood alongside her critique of the romanticized vision of the "West" and demonstrated a different approach to answering inquiries about return. Unlike Kian, who wished not to provide any rational reasons for his return, Mahsa attempted to challenge the assumption held by non-migrants that living in the West is a golden opportunity and a "heaven-like" experience. Given that Mahsa was only away from Iran for two years, she was well aware of the sociopolitical and economic turmoil in Iran. Nonetheless, she felt obliged to provide a seemingly "rational reason" for her return that would align with the non-migrants' expectation of a cost-benefit calculation. Tumaj, a 35-year-old educator, lived in France for seven years before returning to Iran. He had a distractingly long moustache reminiscent of the leftists of the Revolution era in the 1970s -a look now considered hipster in contemporary Iran. He told me that he left with no specific plans for returning, but after a few years abroad, returning seemed inevitable to him. Tumaj perplexed me with his response when I asked why he returned; he confidently probed: "Shouldn't the focus of inquiry be on leaving your homeland rather than on returning to your homeland, to your family and loved ones?" According to Tumaj, the act of returning was both an inevitable and natural occurrence, whereas emigration warranted closer examination. Tumaj's explanation for why he returned to his homeland highlights anticipation of returning regardless of the circumstances surrounding the context of return. Tumaj did not consider the "rational" cost-benefit analysis relevant to his decision to return to his homeland. His response reflects a challenge to my approach to the topic of inquiry, as it shifts the focus from questioning the act of returning to the importance and value of returning to the homeland where one feels a sense of belonging. Tumaj's objection underscores my underlying assumption that return to a challenging context is an atypical and even puzzling phenomenon that warrants further investigation and needs explanation by the return migrants. In retrospect, the phrasing of the inquiry as 'Why did you return?' may appear inquisitorial and judgemental, despite its potential for generating valuable information by prompting return migrants to explain their stories of return. Iranian return migrants often feel obligated to justify why they opted to abandon the opportunity of living in a more socially, politically, and economically stable country in the Global North to return to Iran. However, according to their narratives, returning is a natural course of action that reflects their sense of belonging to their homeland and what it represents. Kian's frustration, Mahsa's idealization, and Tumaj's challenge toward the question exemplify the yearning among return migrants to perceive return as a normal, understandable, and even anticipated occurrence rather than an irrational and perplexing phenomenon. --- The role of family ties in returning to Iran In response to why they returned, the Iranian return migrants spoke about their stay-behind families as a decisive factor that motivated their return to Iran. As per their narratives, family ties play a major role in the return migration decisions of migrants who have established families in their home countries. These ties serve as a powerful motivator for return, given that family members are often regarded as pillars of support within the home country, providing invaluable guidance and assistance which is not easily available overseas. Moreover, the presence of family members upon return can help mitigate the economic challenges that frequently confront return migrants to home countries such as Iran. However, family ties do not only act as a driving force of return for the emotional and practical support provided by the stay-behind families but also when migrants feel a sense of duty towards family members who have remained in the homeland and may need their care. Through the following narratives, we can observe how the rationale for the seemingly puzzling return of the Iranian migrants appears to be a sense of responsibility and obligation toward their family members. --- Returning for family support in the homeland It was a hot summer day in 2018 when I met Kaveh, a 32-year-old engineer who had returned to Iran after living in Canada for two years. I visited him in his office in a government building in Tehran. After navigating through a few corridors, I finally found Kaveh's office. He was sitting behind a wooden desk in a large office which had a window opening toward the beautiful Alborz mountains. He offered me tea as we sat at a table in the middle of the room. Curious about Kaveh's position, I asked about his job. He explained that his job was unrelated to his engineering education, but it was "an easy, well-paid job" that his father secured for him when he returned to Iran. Kaveh spoke at length about his struggles in Canada and shared his experience with loneliness and depression as an immigrant. As he was reflecting on his experience, he said: "Nobody was supporting me in difficult times." These struggles motivated him to seek the support of his family back in Iran. Although he expressed his contentment about his decision to return, he said: "There is one thing that bothers me the most since I returned, and that is being asked why I returned." Kaveh got married a year after returning to Iran, and his marriage was arranged by his family. He told me that he was expecting his first child and was happy to raise his child in his homeland, where he has the support of his family. As immigrants, we often refrain from discussing the challenges we encounter and instead choose to focus on the rosy socioeconomic side of the story. Unfortunately, we tend not to share the emotional difficulties inherent in the immigrant experience and leave those who decide to embark on the journey themselves to discover the hardships firsthand. People may decide differently if they know the full story. And it is often the returnees who tell the full story. This was the account of Jina, a 38-year-old woman who studied at an Ivy League institution in the United States and resided in Canada for two years before returning to Iran. Jina was fashionably matching the colour of her scarf with her long tunic when we met in a café located in the vicinity of the Alborz mountains. The expansive windows in front of our table afforded a remote perspective of Tehran. The metropolis, however, was barely visible due to the thick smog enveloping the urban skyline. The view encouraged us to start our conversation about the sociopolitical and economic challenges in Iran, particularly for women. As an academic with a prestigious degree from the United States, Jina was struggling to find a satisfactory job. We found each other critical of the establishment and the systemic discrimination against women, which Jina was experiencing firsthand when searching for a job. When the conversation moved to immigration and return, I asked Jina why she had returned despite the difficulties she was facing in the country. Jina referred to the challenges of migrant life and offered a critique of other migrants for their tendency to withhold a comprehensive portrayal of the migrant experience. She recounted that her return was very much driven by her intense longing for her family. Jina went on to describe the deep sense of contentment she felt when she was in Iran, surrounded by the sights, sounds, and smells of "home." She asserted that being in the company of her family and receiving their support daily was a source of profound happiness, one that she could not replicate elsewhere. Moreover, Jina expressed strong disagreement with people who equate her return with failure. Her return was a deliberate choice, as she assertively expressed: Sometimes people erroneously assume that your return means that you failed. That's not true! I realized that my happiness in life was tied to being in Iran, surrounded by my family and friends; so, I made a decision to return. The social, political, and economic difficulties in Iran and the opportunities of living in North America are no longer my primary concern. As a returnee, I know the value of family support. The sentiment expressed by Jina about the irreplaceable feeling of happiness she experiences in Iran underscores the profound connection that migrants feel towards their stay-behind families. It also underscores the oversimplified portrayal of return in a dichotomous account of economic success or failure. Hamed, a 35-year-old engineer, migrated to Australia to pursue his graduate studies and start a new life. Upon leaving Iran, he was certain that he "would never want to return." He chose his university based on the information he found on the university's website as well as some brochures. Upon his arrival, however, he realized that his anticipation of the place was far from the reality he faced. He was unhappy about his program, struggled with culture shock, and, most of all, missed the support of his family in Iran. He felt so unhappy and lonely that he ultimately decided to return to Iran before completing his degree. He asserted that he was disappointed about the sociopolitical, economic, and environmental issues in Iran and emphasized that if it weren't for his family , he would have dealt with the challenges of migrant life and never returned to the country. After returning, Hamed stayed with his family, who provided him with support in finding a job and restarting his life in his homeland. His strong regard for his family and his longing for their support brought him back despite his unhappiness about the living conditions in the homeland. Sediqeh, a 38-year-old engineer, made the decision to migrate to Canada while her husband opted to stay in Iran. Sediqeh's husband was concerned about losing his job as an engineer because of emigration and wished to stay close to his elderly parents in Iran. Sediqeh, on the other hand, who was unhappy about the sociopolitical conditions in Iran, especially the systemic discrimination against women, decided to pursue her studies at a college in Vancouver. Nonetheless, it did not take long for her to feel lonely and isolated while struggling with the high cost of living in Vancouver. Sediqeh told me: "It was very difficult for me to live there by myself. I wanted my husband to be there with me. So, I decided to go back." While she expressed satisfaction with her return, she emphasized that if she were to migrate again, she would only do so with her husband at her side. --- Returning to support family members in the homeland Omid, a 37-year-old entrepreneur, lived in Germany before returning to Iran. I met Omid in a large office at his workplace in Tehran in the summer of 2018. He told me in length about the limited opportunities and financial disappointments he faced as a young, educated man in Iran, which seemed to be the main contributing factors that motivated him to emigrate from Iran. Building on the seemingly convincing reasons he mentioned for his immigration, I questioned his return. He then told me: --- Immigration is difficult. For every single thing you achieve abroad, you lose something precious in your personal life you can only have in your country […] you get disconnected from your friends and what gives you a sense of purpose in life. This is what makes immigration difficult the most. Omid's statement piqued my curiosity, and hence, I probed him to give me examples of the precious things that provide him with a purpose and are only available in his home country. That was when he asked us to move to a quiet next-door office where we could continue our conversation without being interrupted by his colleagues during the interview. Omid's voice sounded less assertive and more emotional in the new room, which felt cozier than the previous one. He then revealed a personal aspect of his family life that shaped his migration trajectory. He told me: To be honest with you, I have a sister with special needs whom I wanted to support the most. My parents were separating, and I planned to bring my sister to Germany as a refugee, which seemed to be the only option available for them to join me there [...] I always wished for a better life for her, a better social life. I believed my sister would have been better off in Germany. But she finally decided that she wanted to stay in Iran […] You know, my sister was the main reason I left Iran, and she was the main reason that brought me back. If Omid's financial motive and professional aspirations were the main motivators of his decision to emigrate, going back to Iran would jeopardize them. However, another deeper motivation was in play in Omid's migration journey. His strong sense of responsibility and affect towards his sister shaped his decision to leave Iran in an attempt to pave the way for his sister to join him in a country that, he believed, could provide her with better living conditions. And the same sense of responsibility and affect brought Omid back to Iran when he realized his mother and sister did not wish to live abroad. Furthermore, Omid's story highlights that gender influences decisions about migration movements and settlement. As his parents were separating, Omid, as the oldest son in the family, took on the role of a supportive "father" to take care of his sister, who needed his support. When moving to the United States right before the 1979 Iranian Revolution, Khodanur was not sure he would ever return to Iran again after the establishment of the Islamic Republic. However, he returned after living in the United States for 30 years. When we met at his friend's home in Northwestern Tehran, he enthusiastically introduced himself as "a 70-year-old who had returned to Iran after living in the United States for three decades." Khodanur immigrated to the United States to continue his graduate studies in the United States. After earning his doctorate in education, he stayed in the United States, worked, and raised his family. Khodanur seemed enthusiastic about sharing his story of return which occurred a decade prior to the interview. Assuredly, he told me why he left his life in the United States and returned to Iran: I came back after three decades to take care of my ageing parents. This was when my only sibling, who was looking after them, passed away. My parents needed me; they needed my presence and attention. I returned to my parents; I returned to care. Despite living abroad for three decades, Khodanur's continued sense of responsibility, affection, and care for his parents is a testament to the enduring nature of migrants' ties to their staybehind families. Khodanur's unwavering commitment to his family played a significant role in maintaining his connection to them despite the long separation. Specifically, in the Iranian culture, it is considered a noble duty to care for elderly parents, which can act as a motivating factor in the decision to return to the homeland to look after stay-behind aging parents. Moreover, for return migrants like Khodanur, the sense of responsibility to provide care for parents is strong enough to overcome the advantages of staying in a prosperous country like the United States. As such, taking care of elderly parents can provide a sense of purpose and meaning in life, and hence, it may become more important than the individual financial benefits that can be obtained from living abroad. --- Discussion and conclusion This article has investigated the case of Iranian return migrants to gain a subjective understanding of North-South return migration and to underscore the significance that returnees attach to their return migration trajectory. The primary objective has been to delve into the micro-level, notably focusing on how individual migrants understand and explain their voluntary North-South return migration. I argue that the predominant assumption that return migrants make decisions based on economic calculations of costs and benefits overlooks the complexity and diversity of migrants' decisions to return, particularly in cases where the context of return is not promising. The case of return migration to Iran highlights the important role of stay-behind families in encouraging and facilitating return and underscores the agentic character of migrants who actively participate in shaping their migration trajectory. This article also illustrates that viewing return as a binary outcome, either a success or failure of a migration journey, is an oversimplified perspective. Perceiving return as a failure connotes that individuals who return do not accomplish their desired financial objectives and often cannot integrate into the economic fabric of their host society, ultimately resulting in a feeling of disappointment and "return of failure." On the other hand, the perception of return migration as a sign of economic success views return migrants as "rational" actors who make decisions solely based on cost-benefit calculations. These dichotomous perspectives, however, ignore non-economic motivators, neglect the centrality of family ties, and disregard cultural dimensions and diverse and complex experiences. The multidimensional nature of return migration calls for the inclusion of various experiences, motivations, and aspirations. Specifically, examining how the family is perceived can offer valuable insight into return migration process. In cultures that prioritize more communal values, like Iran's communal culture, migrants often nurture and maintain strong ties with their family members in their home country, placing family at a higher priority in their lives. As such, in the narratives of Iranian return migrants, potential familial tensions are downplayed while the positive and supportive role of the family takes center stage. In addition, the notion of the individual in the rational choice theory, which is informed by the modernist framework of individualism, fails to account for the collective and family-informed decision-making processes that are particularly prevalent in communal cultures. Return migrants inhabit a transnational social field and make decisions and take actions while maintaining their symbolic and material connections with their homelands, specifically with their stay-behind families. The narratives of the Iranian return migrants who participated in this study underscore the centrality of family ties in their decision-making processes of returning to the homeland regardless of its socioeconomic conditions. Families serve as a social unit that, even when physically separated, establish networks of kinship which span across distances and endure over time. Family ties also shape the understanding of return migration and engender a sense of familial responsibility and emotional connection. Such understandings of return influence who decides to return and underline migrants' perceptions about their choice. As such, return migration is a contingent phenomenon in which family ties may play a central role. The narratives of Iranian return migrants highlight that the decision to return home is directly dependent on the ties between migrants and their stay-behind families. While acknowledging the evolving sociopolitical landscape in Iran in the years following this study, particularly in light of the 'Woman, Life, Freedom' movement, one could hypothesize that the notion of family reunion may strengthen in the face of exacerbated sociopolitical and economic hardship in the country. However, the direction of the migration flow might shift towards the movements of those who stayed behind to join their families abroad. Future research in this area will shed light on emerging shifts and dynamics. Finally, the portrayal of countries in the Global North as attractive destinations in every conceivable aspect and the subsequent devaluation of homelands in the Global South as places of struggle to which migrants will not voluntarily return is a continuation of the Orientalist narrative. This depiction of the Global North is also situated within the modernist discourse informed by economic rationality, which underpins many theories of migration . This perspective exhibits an alignment with the unequal geopolitical power dynamics between the Global South and Global North, which place the Southern homelands in a subordinate position and may contribute to anti-immigrant sentiments. In the narratives of the Iranian return migrants, specifically Mahsa, Kian, and Jina, we can also observe what is referred to as "internalized" or "self" Orientalism. In the context of this research, internalized Orientalism can be understood as the process through which individuals from countries in the Global South internalize the idea that Western countries are positioned at a higher rung of the hierarchy compared to the migrants' home countries, portrayed as realms of absolute equality and land of opportunities for all. These narratives show how internalized Orientalism was challenged after migrants gained first-hand experience of life in the West, enabling them to make comparisons based on their own lived experiences. In an attempt to dispel the Orientalist narrative and modernist discourse and to find a more nuanced explanation for North-South return, this study has adopted a bottom-up approach in the investigation and analysis of return migration. As such, I assert that serious consideration of migrants' own perceptions and perspectives regarding their values and priorities is crucial in order to explain the complexities and nuances that underpin migration movements, specifically North-South return migration. --- Declaration of conflicting interests The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. --- Funding The author did not receive any financial support for the research, authorship, and/or publication of this article.

Adopting a bottom-up approach and drawing on semi-structured in-depth interviews with eleven Iranian returnees, this study asks: How do return migrants perceive and articulate what motivated and facilitated their return from a prosperous country in the Global North to the challenging living conditions of their home country in the Global South? How do they explain the role of their stay-behind families in shaping their return migration trajectory? Informed by social network theory, this article showcases the agency of North-South return migrants as active social actors in the process, wherein their return is shaped by transnational relationships, particularly family ties, regardless of the context of return. Family ties act as a driving force of return migration not only when stay-behind families provide emotional and practical support to return migrants but also when migrants feel a sense of duty towards family members who have remained in the homeland and may need their care. This study contributes to scholarship on return migration by undertaking a critical examination of return migration theories grounded in economic models. In the study of voluntary return migration, scholars have focused significant attention on the economic push and pull factors informed by the rational choice theory. The economic models, however, do not fully explain the seemingly puzzling North-South return cases where migrants participate in return migration from a prosperous country to an economically adverse context of their homeland. This study highlights the role of family ties in return migration process and challenges the dichotomous success-failure narrative about return.

Background The factors shaping the health of the current and largest generation of adolescents in human history are multidimensional, complex and unparalleled [1,2]. Until recently, adolescent health has been overlooked and misunderstood, which is one reason why adolescents historically have had fewer health gains than any other age group [1], and hence are now central to a number of major current global health challenges [2]. However, addressing adolescent health potentially provides a triple dividend with benefits now, later in adult life and for the next generation of children [1]. Further, the period of adolescence may also provide a second chance to reduce or reverse early-life disadvantage [3]. In recent decades, theorists have argued that understanding the factors driving growing adolescent health concerns requires a broad focus [4]. Clearly, risk and protective factors of adolescent health include levels of physical activity, substance use, alcohol consumption, tobacco usage [5], diet [1], adolescent abnormal weight and mental health [5]. However, it has been asserted that as well as focusing on an individual's health risk and protective factors, the upstream social patterns and structures in which adolescents exist needs to be considered [4]. Ecological theorists [6] argue that an individual's social environment, both present and past, influence their health behaviors and health outcomes, mediated by other factors including their demographics and physical and psychological makeup. Social environments are multifaceted and include peer, school, community, societal, cultural, new media influences and family dynamics [7]. Adverse childhood experiences such as psychological, physical or sexual abuse, violence, parental substance abuse, parental separation/divorce, parental incarceration or death of a parent, close relative or friend may also influence health behaviors and health outcomes in adolescents [8][9][10][11]. Conceptual frameworks have been developed to represent the complex web of causal "pathways" through which social factors interact with an individual's health risk and protective factors throughout the life course [12]. However, these models have not been tested among adolescent populations. Self-rated heath is a legitimate and stable construct used in adolescent populations [13][14][15][16][17][18][19][20][21]. Reviews by Idler and Benyamini [19] proposed that an individual's health status cannot be assessed without the SRH measure as it captures an "irreplaceable dimension of health status," spanning past, present and future physical, behavioral, emotional, cognitive [22] and social [20] dimensions of health. Widespread agreement in the literature [15,[23][24][25]] recognizes that SRH is a complex parameter affected by multifarious determinants. Specifically, SHR is influenced by higher body mass index [17], mental health select health behaviors [20] , demographics and social factors . Many of these factors have complex interrelationships [23], directly or indirectly affecting self-perception of health status [15]. While an increasing number of studies have been reported on SRH among adolescents [13], most research in this field [13][14][15][16][17][18][24][25][26] address only select factors Fig. 1 Conceptual Framework for Determinants of Health affecting health status, and thus yield only partial or confounded information on the determinants of adolescent health [23]. Investigations need to assess concomitantly the factors associated with this multi-faceted health measure [23]. Utilizing structural equation modeling and SRH as a measure of health status, this study aimed to explore concomitantly the complex relationships between SRH and social environments, health behaviors and health outcomes among adolescents attending a faith-based school system in Australia. --- Methods --- Study design and participants In 2012, 1734 students aged 12 to 18 years of age responded to a health and lifestyle survey that was administered in 21 Seventh-day Adventist private secondary schools in Australia. The database created by this survey has been used in previous studies [27,28]. Seven hundred and eighty eight students from this database met the inclusion criteria for this study which included useable data for the following domains: SRH, BMI, Mental Health, and Vitality. Notably, BMI data were not collected on over 900 students in the database, hence these cases did not meet the inclusion criteria. The study was approved by the Avondale College of Higher Education Human Research Ethics Committee , and participation in the study was voluntary and anonymous. A hypothesized model informed by ecological theory and the conceptual framework for determinants of health [12] is presented in Fig. 2. The dependent variable was the measure SRH. In order to concomitantly explore factors associated with SRH yet retain a parsimonious model, we delimited the study by restricting the explanatory variables to the following: health outcome variables ; health behavior variables ; and demographic and social variables , religious affiliation). --- Survey instrument The survey instrument recorded the participant's SRH as well as: BMI; measures of mental health and vitality; selected health behaviors; personal demographics; and social influences. Self-rated health status SRH status was assessed with a single item involving a five-point Likert scale ranging from "Excellent," "Very Good," "Good," "Fair" and "Poor." --- Body mass index Height and weight were self-reported and used to calculate BMI using the standard equation: BMI = weight in kg/ 2 . --- Mental health and vitality Mental health and vitality were measured using the validated and reliable [29] five-item mental health and fouritem vitality subscales from the SF-36 [30]. These subscales measure general mental health status and assess the individual's energy and fatigue. Each item in the mental health and vitality subscales has six response options ranging from "All of the time" to "Not at all." Standardized scores for these subscales were calculated creating a 0-100 scale according to the standard procedure for calculating the mental health and vitality scores [31]. Higher scores indicated better mental health and vitality. Internal reliability of the mental health and vitality subscales have been reported at α = .78 to .87 and α = .72 to .87 respectively in studies across eleven countries [32]. As seen in Fig. 2 Hypothesized Model for Factors Associated with Self-Rated Health in Adolescents Table 1, the reliability of vitality in this study was comparatively lower than in these reports. --- Selected health behaviors Sleep hygiene was assessed by an item that asked: "How many hours do you usually sleep per night?", with eight response options ranging from "3 h or less" to "10 h or more". Physical activity was measured by an item that asked: "How many times per week do you usually do any vigorous or moderate physical activity for at least 30 minutes?", with seven response options ranging from "none" to "6 or more times" [33]. Fruit and vegetable intake was assessed using food frequency questions adapted from items previously used in adolescent studies [34]. Fruit consumption was measured by an item that asked: "How many serves of fruit do you usually eat each day? ". Response options ranged from "I do not eat fruit" to "6 serves or more". Vegetable consumption was measured by an item that asked: "How many serves of vegetables and salad vegetables do you usually eat each day? ". Response options ranged from "I do not eat vegetables" to "6 servers or more". The fruit and vegetable items were summed to provide an overall fruit and vegetable intake score. As a measure of the respondents' overall diet, an item asked: "How would you describe your usual diet?" Response options included: 1. "Total Vegetarian "; 2. "Lacto-ovo vegetarian "; 3. "Pesco-vegetarian "; 4. "Non-Vegetarian ". For the purpose of this study, this item was dichotomized as a vegetarian or non-vegetarian diet . This item was included in the study because a high proportion of Adventists adhere to a vegetarian diet [35]. Alcohol consumption, tobacco and marijuana use were assessed with frequency questions ranging from "none" to "60+" for alcoholic drinks drunk and cigarettes or marijuana smoked in the last four weeks. --- Religion Religious affiliation was included in this study due to the special nature of the sample. Previous studies report associations between religion and SRH [36] with some reviews reporting that this association is unaffected when controlling for demographic variables [37]. Religious affiliation was assessed by asking the participants: "Which of the following best describes your religious belief now?" Options ranged from: 1. "Seventh-day Adventist Christian", 2. "Other Christian", 3. "Other Religion", 4. "No Formal Religion", and 5. "Don't Know". This item was dichotomized to "Non-Adventist" , and "Adventist" . --- Social factors In this study, an Adverse Childhood Experiences score [8][9][10][11] was generated by collating responses from the following nine items: 1. "One or both of my parents were in trouble with the law," 2. "My parents were separated or divorced," 3. "One or both my parents died," 4. "One or both parents were absent from home for long periods," 5. "There were times when family violence occurred," 6. "There were times when I was physically abused," 7. "There were times when I was sexually abused," 8. "One or both parents smoked tobacco," and 9. "One or both parents drank alcohol weekly or more often." Each of the nine items included no/yes response options which were given a corresponding value of zero or one. Responses from each item were summed to calculate an overall ACEs score. Childhood family dynamics were assessed by creating a CFD score from six items, namely: 1. "As a child, my parents showed me love," 2. "As a child, my parents understood me," 3. "While I was a child my family had a lot of fun," 4. "As a child, my parents didn't trust me," 5. "As a child, my parents didn't care what I did," and 6. "As a child, I enjoyed being at home with my family." Each item included five response options ranging from "strongly disagree" through to "strongly agree." Each response was given a corresponding value from one to five and was recoded so that higher scores represented positive outcomes. Responses from each item were summed to calculate the overall CFD score. --- Analysis The objective of this study was to simultaneously analyze all paths of the hypothesized model in order to explore the complexity of the associations between multiple factors and SRH. Hence, structural equation modeling [38] was used to estimate the model fit of the data and analyze the direct and indirect effects of the multiple factors in the hypothesized model. Overall model fit was examined using multiple goodness-of-fit indices, namely; chi-square statistic , relative X 2 , baseline comparisons fit indices of NFI, RFI, IFI, TLI, CFI, and RMSEA. Structural equation modeling was carried out using AMOS . The Bootstrapping method [39] was applied to verify statistical significance of indirect and total effects at p < .05. The data were imported into SPSS to calculate means, standard deviations, distributions and internal reliability. --- Results --- Descriptive statistics A summary of descriptive statistics and reliability estimates is shown in Table 1. Sixty-one percent of the students in the study reported "very good" to "excellent" health. This is comparable with the 2014-15 Australian Bureau of Statistics survey [40] which reported that 63% of young Australians rated their health as very good or excellent. Unique to the study cohort was that 49% of the students reported an affiliation with a Christian faith and low rates of alcohol consumption tobacco use and marijuana use . --- The model for factors associated with self-rated health in adolescents The hypothesized model based on theoretical considerations was submitted for analysis using techniques developed by Jöreskog and Sörbom [41] utilizing an iterative process of inspection of the statistical significance of path coefficients and theoretical relevance of constructs in the model to derive an optimal SEM that best fit the dataset and were theoretically meaningful. The items that asked the participants about alcohol, tobacco, and marijuana use were removed from the model due to their non-significant contributions generating a final structural model . Modification indices suggested that the health behavior variables be allowed to covary, as well as the health outcome variables mental health and vitality. The final structural model as a whole fitted the data very well, as indicated by the goodness-of-fit indices . CMIN/DF statistic below three is considered good model fit [42] as are baseline comparisons fit indices above 0.9 [43]. The RMSEA value was less than 0.06, which indicated a close fit between the data and the model [44]. In Fig. 3, the standardized path coefficients are presented as single-headed arrows, and all shown paths are statistically significant including all indirect and total effect pathways. The final structural model describes the upstream associations of BMI, mental health and vitality, health behaviors, demographics and social factors on SRH as well as their interactions. The squared multiple correlation calculated for SRH was 0.20 which indicates that the model explained 20% of the variance in selfrated health. Based on standardized path weight coefficients , the health outcome variables BMI , mental health and vitality had a direct association with SRH. This indicates that adolescents who reported a higher BMI reported a poorer SRH, and adolescents who reported higher mental health and vitality scores reported better SRH. The health behavior variables sleep hours , physical activity , fruit/vegetable consumption and a vegetarian diet had a direct association with SRH. This indicates that adolescents reporting more sleep each night, more physical activity, greater consumption of fruit and vegetables and a vegetarian diet also reported a better SRH. The health behavior variables were also associated with SRH indirectly through the health outcome mediating variables. Sleep hours was associated with SRH indirectly through the mediating health outcome variables BMI, mental health and vitality. Physical activity was associated with SRH indirectly through the mediating health outcome variables mental health and vitality. Fruit/vegetable consumption was associated with SRH indirectly through the mediating health outcome variables mental health and vitality. A vegetarian diet was associated with SRH indirectly through the mediating health outcome variable vitality. Of the health behavior variables, sleep hours had the strongest combined direct and indirect association with SRH followed by fruit/ vegetable consumption , physical activity and then vegetarian diet . Of the demographic and social variables, ACEs was the only variable that had a direct association with SRH with the other demographic and social variables indirectly associated with SRH. Age was associated with SHR through the mediating health behavior variables sleep hours and physical activity, and through the mediating health outcome variables BMI and mental health. Gender was associated with SHR through the mediating health behavior variables sleep hours, physical activity, fruit/vegetable consumption, and vegetarian diet, and through the mediating health outcome variables BMI, mental health, and vitality. ACEs was Fig. 3 Structural Equation Model Predicting Self-rated Health Status associated with SHR directly and through the mediating health behavior variable sleep hours and the mediating health outcome variable mental health and vitality. CFD was associated with SHR through the mediating health behavior variable sleep hours and through the health outcome variable mental health. Religious affiliation was associated with SHR through the mediating health behavior variables sleep hours, fruit/vegetable consumption and vegetarian diet. Notably, of the demographic and social variables in the model, ACEs had the strongest association with SRH . Hence, more ACEs were associated with lower SRH. Gender had the second strongest association with SRH of the demographic and social factors and also interacted with the greatest number of the mediating variables in the model. The association of age on SRH demonstrated that older adolescents reported poorer SRH, however, overall, males rated their health better which is in line with other studies [13]. The association of CFD on SRH demonstrated that adolescents reporting better CFD also reported better SRH. Finally, the model indicated that although the respondent's religion did have indirect links to SRH its association was small . Adolescents who identified as Adventist were more likely to report higher SRH, and better health behaviors than those who identified themselves as not affiliated with the Adventist Church. --- Discussion This study explored concomitantly the relationships between factors associated with SRH in adolescents attending Adventist schools in Australia. By including a number of variables into one conceptual model and analyzing them simultaneously, the study is unique in that it was able to describe a complex network of associations between the factors that influence SRH. This study supports the need for a broad multi-component approach to the study of adolescent health. The findings in this study demonstrate the association between mental health and SRH which is in line with findings from previous studies [20,22]. The mental health measure used in this study had the strongest association with SRH of the three health outcome variables measured and was associated with the most health behaviors, demographics and social variables in the model. Several health behaviors , as well as demographics , and social factors had a direct association with mental health. Notably, the association between the adolescent's childhood upbringing and mental health demonstrates how social factors early in life are associated with mental health status years later in adolescence. The vitality metric used in this study had the second strongest association with SRH of the health outcome variables. All health behaviors in the model along with gender and ACEs directly associated with the measure vitality. Research on vitality is limited; however, one study found that up to 30% of healthy teens experience symptoms of fatigue that affect their normal functioning [45]. The observed influence of health behaviors on vitality in this study highlights the importance of targeting healthy behaviors for improving the energy levels and lessening fatigue among adolescents. There is a wealth of literature supporting the importance of health behaviors on adolescent health [3], however, a unique aspect of this study was the simultaneous assessment of the association of four health behaviors with SRH. This allowed the health behaviors to be ranked according to their strength of association with SHR. While all health behaviors had a direct association with SRH and an indirect association through one or more of the health outcome variables, sleep had the strongest association with SRH, followed by fruit/vegetable consumption, physical activity, and vegetarian diet. This finding highlights the value of prioritizing healthy sleep hygiene among adolescent cohorts [46], although clearly, interventions that address all health behaviors are likely to be most efficacious and therefore desirable. In the SEM analysis, the items measuring the health behaviors: consumption of alcohol and the use of tobacco and marijuana had non-significant pathways to SRH. It is well documented [5] that these health behaviors influence adolescent health negatively. A possible explanation for the non-significant effect of these health behaviors in this study may be that the study cohort reported a low prevalence of these behaviors. While this low prevalence was expected given the Adventist community proscribes such behavior, further exploration as to what motivates the use of alcohol, tobacco and marijuana in a low using cohort would be of interest. Of the selected demographics and social factors included in the model predicting SRH, ACEs presented as having the strongest association. Indeed, it is remarkable that adolescents who reported higher incidents of adverse experiences in their earlier childhood, reported poorer SRH in their adolescent years. Although children may have no choice in the ACEs they experience, this study reinforces the necessity for childhood human rights, health promotion and resilience building [47] to be at the forefront of global policy and intervention development to provide benefits not only in childhood, but also later in adolescent life. Of the five demographic and social factors assessed, gender had the second strongest association with SRH, and was associated with the most number mediating variables, interacting with all health behavior and health outcome variables in the model. This suggest that interventions targeting improving general health of adolescents may be more effective if they were gender specific. The influence of CFD and religion on SRH in this model is noted, albeit not as strong as ACEs and gender. --- Strengths and limitations The strength of this study is that it concomitantly explored a number of factors associated with SRH and describe the complex interaction between these factors and SRH. It is acknowledged, however, that model presented in this study, although strong, represents only part of the big picture of the overall influences of SRH. For example, socio-economic status is a well-known predictor of SRH [17], and this was not assessed in this study as no data on socioeconomic status was collected. Another limitation of this study is that it focused on a comparatively homogeneous group of adolescents who were exposed to a faith-based community, namely, Adventist Christians who place a strong emphasis on health and a wholistic lifestyle. Since its inception in 1863, the Adventist religion has promoted the adoption of a healthy lifestyle to its members that includes regular exercise, a vegetarian diet and rest. Alcohol, caffeine, tobacco and illicit substances are also proscribed . The Adventist population has been the focus of numerous health studies as they tend to experience good health and lower rates of disease [48]. Adventist schools espouse the health practices of the Adventist church. Hence, while approximately half of this study cohort did not identify themselves as Adventist, they were likely influenced the by health focus of the Adventist church. It is possible that the adolescents in this study potentially underscored their self-rated health status compared to adolescents in the general population due to the high health ideals advocated by the faith-based schools they attend. This may have resulted in these adolescents perceiving and judging "very good" or "excellent" health against a more rigorous standard. This limits the generalization of the findings to other populations. The cross-sectional nature of this study means that only associations could be measured, it is not possible to say whether these relationships were causal. Although SRH has been established as a legitimate and stable construct for use in adolescent populations [13][14][15][16][17][18][19][20][21] to measure general health status, objective measures of health including biomedical testing as represented in the conceptual framework for determinants of health [12] may improve the validity of the findings in this study. --- Conclusion This study presented a conceptual model that described the complex network of factors concomitantly associated with SRH in adolescents. The results highlight the association of mental health with SHR. Gender-sensitive interventions prioritizing modifiable health behaviors such as sleep, healthy diet, and physical activity may achieve a greater combined effect in improving adolescent health status than select single factor interventions. The association between ACEs and adolescent SRH reinforces the necessity to address childhood human rights, resilience, family dynamics, and health promotion in children for lasting benefits later in adolescent life. Further research into what influences the variables interacting with SRH may provide insight into more effective interventions to improve adolescent health. --- --- Abbreviations ABS: Australian Bureau of Statistics; ACEs: Adverse childhood experiences; BMI: Body mass index; CFD: Childhood family dynamics; CFI: Comparative Fit Index; CMIN: Chi-square statistic; CMIN/DF: Relative X 2 ; IFI: Incremental fit index; NFI: Normed Fit Index; RFI: Relative fit index; RMSEA: Root Mean Square Error of Approximation; SEM: Structural equation modeling; SRH: Self-rated health; TLI: Tucker Lewis index; X 2 : Chi-square Authors' contributions BC, DM, LK, PR and BG conceived of the study, participated in its design and coordination. TB and KP coordinated the data collection. BC and PM performed the statistical analysis and data interpretation. BC drafted the manuscript and DM, PM, LK, BG, PR assisted in critical revision of the manuscript. All authors read and approved the final manuscript. --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: The factors shaping the health of the current generation of adolescents are multi-dimensional and complex. The purpose of this study was to explore the determinants of self-rated health (SRH) of adolescents attending a faith-based school system in Australia. Methods: A total of 788 students attending 21 Seventh-day Adventist schools in Australia responded to a health and lifestyle survey that assessed SRH as well as potential determinants of SRH including the health outcomes mental health, vitality, body mass index (BMI), select health behaviors, social factors and personal demographics. Structural equation modeling was used to analyze the data and examine the direct and indirect effects of these factors on SRH. Results: The structural model developed was a good fit with the data. The health outcome mental health had the strongest association with SRH (β = 0.17). Several upstream variables were also associated with higher SRH ratings. The health behavior sleep hours had the strongest association with SRH (β total = 0.178) followed by fruit/vegetable consumption (β total = 0.144), physical activity (β total = 0.135) and a vegetarian diet (β total = 0.103). Of the demographic and social variables measured, adverse childhood experiences (ACEs) had the strongest association with SRH (β total = -0.125), negatively influencing SRH, and gender also associated with an increase in SRH (β total = 0.092), with the influence of these factors being mediated through other variables in the model.This study presents a conceptual model that illustrates the complex network of factors concomitantly associated with SRH in adolescents. The outcomes of the study provide insights into the determinants of adolescent SRH which may inform priority areas for improving this construct.

Introduction The goal of marriage is to create a family, find happiness, and love based on the One Godhead. It is a socially controlled bond between a man and a woman in which rights and obligations, emotional togetherness, as well as sexual and economic activities, are regulated. --- TSBEC Making the decision to marry young is not simple for some people. The sacred promise is tied together by several factors. Women who plan to have children later, in particular, need to be able to mentally and physically get ready. Women between the ages of 15 and 16 are not physically prepared to become pregnant or give birth. A woman's ideal body has not yet developed at that age. The waist of a woman who gave birth to a minor is still not growing properly, making it impossible for her to give birth idealy. If the waist has not grown perfectly but the woman is already pregnant, it will typically affect the size of the brain. This was revealed by psychologist Kasandra Putranto from a psychological point of view. As a child grows, the brain's volume naturally decreases. It is thought that children born to very young mothers will have disturbed abilities. The mother's waist, which did not expand properly during childbirth, is the direct cause of this. The quality of Indonesian people will eventually decline due to the low quality of children produced by young children who are not yet developed physically or mentally. Before getting married, one should consider their physical, mental, social, and financial readiness, in his opinion. because it will also have an impact on the child's development as an adult. It is better for young married couples to put off having children because an adult's quality will undoubtedly depend on genetic factors, the learning environment, and mental readiness. The readiness of all facets of life is just as important to having children as pregnancy and childbirth. Before having children, it is advised for young couples to grow spiritually, mentally, and physically. The birth must be postponed if they are not prepared. He now believes that adultery is preferable to getting married later. However, everything needs to be mentally, physically, and psychologically prepared if you want to have kids. Early marriage affects the likelihood of a discordant family being formed. Generally speaking, young couples are still stable in handling issues that arise in marriage because they are psychologically immature. Because of this, issues that arise in the home are not properly resolved and instead become more challenging. Marriage at a young age will inevitably lead to a number of unforeseen issues due to the psychological component's immaturity. Because of a too-new marriage, it is not uncommon for couples to experience a breakdown in their home life. Indeed, because everything is given back to each person, household harmony is not solely based on age. But a person's mental and physical state typically change as they age. When it comes to resolving issues, youth tends to be stable, but it also results in frequent arguments and disagreements that end in divorce. Young marriages also result in a lack of socioeconomic maturity for the couple. Since they typically don't have a steady job, financial hardships also lead to conflicts in the home. emotional instability and ignorance of newlywed couples. DOI 10.18502/kss.v8i12.13694 TSBEC Physical, mental, and financial preparation are all necessary for marriage. Marriage between two people requires more than just love, it also requires commitment and careful planning because married life will begin after becoming legally wed in the eyes of law and religion, not just during a celebration [1]. Law Number 1 of 1974, which later became Law Number 16 of 2019 concerning Marriage, established the rules for marriage in Indonesia and raised the legal marriage age from 16 to 19. Early marriages are the remainder of the marriages consummated below this bare minimum. In Cintapuri Village, Banjar Regency, Banjarmasin City, the emphasis on continuing young marriages has not changed much, according to the reality on the ground. The majority of these teenagers, especially female students, will not continue their education past junior high school because they immediately decide to get married. This young marriage typically takes place after these teenagers graduate from junior high school. It's hard to break the habit and tradition of this recent marriage. The women in the village believed that they would feel much more comfortable and live happily after marriage, but the young couples made the decision to get married on their own, citing the fact that they were tired of continuing their education to the next level. Parents also don't stop their kids from getting married young; instead, they prefer that if they already have a significant other, they get married right away out of concern that if they get pregnant outside of marriage, it will be considered shameful by the family's religion. In rural areas, young marriage is shaped by the existing factors as a natural phenomenon. Another benefit of marrying girls young is that it will lessen the financial strain on the family because when parents' daughters get married, they are already their husbands' responsibility and they are worried that their kids will become spinsters if they are not married right away at a young age. Based on the context and focus of research on the phenomenon of early marriage for young women, this study aims to identify the variables that affect the marriage of young women in Cintapuri Village, Banjar Regency, Banjarmasin City. --- Literature Review A review of previous research findings pertaining to the issues raised, theoretical studies investigating the issue, and a framework of thought that combines these theoretical studies are all included in the literature review. This chapter discusses theoretical studies that are connected to the findings of related studies and research variables. --- Review of past research According to Velentza, the prevalence of such problems is especially high among the Roma population. Based on these findings, it is clear that early marriage is regarded as a highly significant cultural practice and a pillar of national identity among some traditional Roma groups in the Transylvania region. In addition, some Roma groups who engage in this practice see it as a means of shielding young women from the influence of the "evil white people" and a means of empowering them to take on more responsibilities as members of society. There are negative outcomes associated with child marriages that occur without parental consent, including underage pregnancies among females, diminished rights, social isolation, and even domestic violence. In the traditional societies we encountered, early marriage is a factor in the educational abandonment of poor children [2]. As shown, community variables are significant predictors of both union formation and childbearing even after controlling for individual traits. There are a number of important personal factors that influence teenage family transitions, including women's education, the socioeconomic level of homes, and the presence of a female breadwinner or adolescent's residence in a rural location. We analyze the results in light of the post-2015 framework for development in sub-Saharan Africa and the need to revitalize stagnant fertility transitions [3]. Due to the high rate of young marriages in the district, Astuti's research shows that women in Pamulang District, South Tangerang, have low levels of formal education. Since the high rate of early marriage in this subdistrict actually makes it more difficult for girls to pursue formal education, the advancement of civilization and the changing mindset of the community have no impact on the community's beliefs and traditions [4]. This study explains how socio-cultural factors, specifically the custom of getting married young, influence how much formal education women in Sumberdanti Village receive. In Sumberdanti Village, girls typically marry between the ages of 14 and 16. At this age, kids start receiving formal education [5]. Parents in this village gave various explanations for why they married off their daughters when they were young, including that they did so in accordance with the local custom. They still adhere to the old custom that their daughters must be married off DOI 10.18502/kss.v8i12.13694 TSBEC right away or else they will not be able to sell them or they will grow up to be virgins. Social, cultural, and economic circumstances are additional contributing elements. The research in Cintapuri Village, Banjar Regency, and the four earlier studies are comparable in that they both discuss the custom of young marriage, which contributes to the low level of education of village women. From the research mentioned above, it can be inferred that rural communities' still-evolving cultures, traditions, customs, and religions among them, the custom of young marriage have an impact on women's low sociocultural education. Parents still adhere to the traditions of their ancestors for a variety of reasons, including the belief that if they do not immediately marry off their daughters, the girls will not sell and become old virgins. This tradition is greatly influenced by parents' views on the customs that developed in their village. --- Factors that cause marriage at a young age According to Handayani's research, there are several factors that contribute to the high rate of early marriage. The first is that young women with low levels of education are 2.3 times more likely to get married young than those with higher levels of education. Second, young women who grow up in a bad environment are 2.1 times more likely to get married young than those who do. Third, compared to young women with higher education, young women with low education are 5.4 times more likely to marry young [6]. Fourth, compared to young women whose parents are employed, those whose parents are not employed will have a 7.4 times higher risk of getting married young. Therefore, it can be inferred that an economic factor is always the most dangerous one driving children to marry young, specifically when both of their parents are unemployed. They both don't want to be bothered any longer, whether it's due to their parents' wishes or their kids' wishes because they understand that their parents can no longer afford to support them. On the other hand, this is extremely alarming. The parent who can no longer bear the child and the child are both still minors. There are many reasons why parents marry off their minor children. The first is an economic one, where parents choose to marry off their child to someone who is deemed to be more capable because they cannot afford to support their child because they have more than five children, for example. Due to the fact that even though they would like to continue their education, their parents cannot afford to send DOI 10.18502/kss.v8i12.13694 TSBEC them to school, women choose to get married rather than finish their education, which lowers the level of education among women. The second factor is a society's low level of education, which has a significant impact on both the child's and parents' education levels. A highly educated society will undoubtedly consider marriage to be the umpteenth thing and will doubtlessly think twice about getting married. Contrary to those whose education is still limited, they will prioritize marriage because only then will they be able to fill the void left by their children's days and meet their own needs. A person's personality maturity is influenced by their level of education; more educated people are more likely to be filtered, accept positive change, and react to situations that may impair their ability to think. The third is the actual desire factor. Because men and women believe they are in love regardless of age, problems they may face, or whether they can solve a problem, it is very difficult to avoid this factor. A marriage will be threatened with divorce if a problem cannot be resolved on the grounds that their minds are no longer in harmony. If you want to get married when you're young, that should be a concern. Promiscuity is the fourth factor. Children who lack parental guidance and attention will find a way to feel happy by hanging out with people whose behavior is not immediately obvious . Getting pregnant outside of marriage is something that occurs frequently. Consequently, whether they like it or not, parents will consent to their minor children getting married. The fifth is a Customs Factor item. According to tradition, marriage frequently takes place because the child has been engaged by his parents since he was a young child. That the marriage of children will immediately establish the kinship ties that the bride's and groom's families have long desired to share, in order to prevent the breakdown of their family relationships [7]. Parents immediately find a partner for their child because they are worried about their daughters, who are already teenagers, and other factors. Parents in rural areas typically want to marry off their daughters as soon as possible out of fear of becoming spinsters [8]. The mass media is also a contributing factor in early marriage. Modern teenagers are becoming more open to having sex as a result of the constant exposure to sex in the media. Early marriage is frequently caused by a variety of factors, such as parental legitimacy, social power, and involvement. Poor girls who are unable to complete their education or who have quit school are more likely to get married young, and living in a rural area makes it difficult to learn about the effects of early marriage. That has a significant impact on the practice of early marriage. Early marriage carries a number of risks for women, including those related to biology and DOI 10.18502/kss.v8i12.13694 TSBEC psychology . Both men and women shoulder a lot of responsibility in the home. The loss of a child's rights is another effect. The loss of a child's right to health is followed by psychological issues like anxiety and even depression. Additionally, those who marry young run the risk of living in poverty for the rest of their lives. --- The impact of marriage at a young age UNFPA estimates that 33,000 girls under the age of 18 will be married off against their will, most often to men much older than themselves. One in nine Indonesian women in their twenties and twenties-plus are married before they turn eighteen. Indonesia ranks eighth worldwide in terms of the prevalence of child marriage, with 1.2 million reported cases as of 2016. Child marriage is a form of violence against children and is a practice that violates the basic rights of children. As a type of abuse, child marriage is a serious problem that has to be addressed immediately. Because of their age, children who get married before they become 18 are more likely to be victims of violence and to continue a cycle of poverty that can affect their entire families. There is a higher risk of maternal and infant mortality among teenage brides compared to older brides, and a higher chance of maternal death overall. As a result of the following five factors, young couples are less likely to have children. At the outset, it stunts kids' physical and mental development. For another, it may lead to an increase in cases of cervical cancer in females because reproduction is not yet fully developed. The third issue is that children's rights to participate in society and receive a quality education are not being met. A lack of readiness can lead to domestic violence, which is the fourth risk. To cap it all off, it might be bad for the economy [9]. Some of the benefits of getting married young include not having to worry about taking care of a little child when you're older and never having to engage in free sex. There is an idea that if you are married at a young age, you will live to a ripe old age without any more small children, which is excellent from a religious standpoint since it reduces the likelihood of adultery and free sex behavior. One more good consequence of early marriage is that it relieves pressure on parents by ensuring that their son's requirements will be met once he marries [10]. The drawbacks of marrying young list of young people: psychological development that would influence how they raise their children. As a result of being cared for by a young couple, the child will not receive the utmost in parental affection. From a societal DOI 10.18502/kss.v8i12.13694 TSBEC perspective, getting married limits your ability to grow as an individual, prevents you from furthering your education, and makes your family look bad to your neighbors. There are some kids who married so young that they have to drop out of school to avoid shame. Marrying at a young age is harmful to one's health because it raises the probability of problems during pregnancy, labor, and delivery, as well as the mortality rates of both the mother and her newborn. This condition poses a greater threat of death and disability to infants than it does to adults. Babies with hypoxia ingested amniotic fluid and the teen had to have a cesarean section since she went into labor late. The proportion of marriages ending in divorce is alarmingly high. The likelihood of divorce increases when families struggle to cope with a wide range of difficulties. In some instances, the divorce rate rises because of the impact of getting married at a young age [11]. Given the framework above, it is clear that cultural, educational, and economic factors all contribute to young marriage in Cintapuri Village. Despite the fact that the marriage law specifies a maximum marriage age of 19 years for both men and women, these factors lead women in Cintapuri Village to get married between the ages of 14 and 16. --- Framework of thinking The marriage law exists because young marriage is still a custom in this village. Those who are married by the KUA before turning 15 years old are granted the convenience of getting married, specifically by requesting parental consent and a dispensation from the Banjar Regency Religious Court. Parents marry off their daughters at a young age out DOI 10.18502/kss.v8i12.13694 TSBEC of fear that their daughters will not marry, become spinsters, or for other reasons, that if they are not married, they will commit adultery and have children outside of marriage. --- Methods This study's methodology is a qualitative approach. Qualitative research aims to comprehend the phenomena of what research subjects perceive holistically, through description in the form of words and language, in a setting that is uniquely natural, and by applying a variety of natural methodologies [12]. This study views the component as a whole rather than isolating individuals or organizations in variables or hypotheses. The study's methodology was phenomenological descriptive research. The goal of phenomenological research is to relate events to human existence. The purpose of this study is to outline the causes of the increase in young marriages in Cintapuri Village. The purposive sampling technique was used to choose the study participants. Women who were married between the ages of 14 and 16 made up the majority of the informants; their last educational level was junior high. The parents of the main informants and the Cintapuri Village apparatus are supporting informants because they are knowledgeable and capable of sharing information about the village from the total population, including both male and female residents, village residents' education, village traditions, and other sources. Parents and husbands of research participants who are aware that age is a factor in marriage are also included. Observation, documentation, and interview-based data collection methods. Data reduction, data presentation, conclusion drawing, and data checking are all components of the qualitative data analysis used in the data analysis technique. The Village Office is 30 kilometers from the Regency Capital. There are 1,283 male population populations and 1230 female population populations. 819 households have 819 heads of household. The number of people who identify as Muslims is 2,501, while there are 12 people who identify as Christians. --- Results and Discussion --- Overview of research objects --- Research results Self-marriage is caused by a variety of factors in Cintapuri village, including economic, educational, and customary or habitual factors. There are effects that result from this phenomenon as well. --- Discussion The economic burden on the family often encourages parents to immediately marry off their children in the hope that the family's economic burden will be reduced. This happens a lot in the village of Cintapuri, regardless of the age of the child, especially if the applicant is from the rich. Even parents hope that after their children get married, they can help their parents' lives. Economic problems, lack of income and the needs that are needed are not in accordance with the income obtained. With the economic condition of the people in Cintapuri Village, there are not a few factors, besides income that is not permanent, the number of children borne by parents is not like in urban areas. So with non-permanent income, they are unable to pay for their children's education. Parents have a role and basis for the successful development of children, while the duties and responsibilities are a shared task between parents, society and the government as well as the children themselves. The lack of education and knowledge among parents, kids, and the community leads to a propensity for parents to marry off their minor children without giving it much thought as to the repercussions and effects of the issues encountered. Parents will be pleased if their daughter already likes it because of the low level of education between them DOI 10.18502/kss.v8i12.13694 TSBEC and their kids, who are only educated through junior high school , and because parents are unaware of the negative effects of getting married young. According to several interviewees, parents who don't attend school or have low levels of education are less likely to understand and be aware of the effects of early marriage. Many members of the public believe that marriage frequently occurs because parents have been tying up their children since they were young. In order to prevent the breakdown of their family relationship, it is imperative that the groom's and bride's families immediately recognize the kinship ties that they have been longing to form. so that parents can match their child up right away. In Cintapuri village, parents typically believe they want to marry off their daughters out of fear that they will age into old virgins. According to some informants, Cintapuri village residents' customs and mentalities are what prompt them to wed off their kids right away. As there are still many matchmaking customs in the village of Cintapuri, they are concerned that their children will become spinsters if they remain celibate for an extended period of time. Parents who still have a traditional outlook on life often marry off their kids before they are old enough to marry off on their own. These parents do this out of fear that their neighbors will gossip about them if their kids wait too long to get married. Early marriage is when two people marry while they are still minors, which can be harmful to both parties. Early marriage is a young marriage whose preparation goals-including material, mental, and physical preparation-have not been said to be maximal. Because everything hasn't been carefully planned out, early marriage can be considered a rushed marriage. In addition to causing legal issues and breaking laws governing marriage, child protection, and human rights, early marriage among women also increases the risk of disease in women and increases the likelihood that childbirth will be dangerous for both the mother and the unborn child. Early marriage is associated with a high risk of cervical cancer, neurotic depression, and marital conflicts. Early marriage makes it difficult to tell whether the partner is a boy or a girl because girls are typically better at controlling their emotions. It is difficult to return to normal circumstances because their emotional state is obviously unstable. Giving them advice after a problem has been discovered is preferable to giving them prevention before a problem arises. People typically discover issues once they have children. Everything changes completely once you have kids. Even though they are bound by the constraints of marriage, this couple can still enjoy life if they are still childless and alone. This is especially true if they both come from relatively wealthy families. Because of their young age, many people make poor decisions because they are motivated by their emotions or even out of love. DOI 10.18502/kss.v8i12.13694 TSBEC Since people start to enter adulthood at the age of 24, emotional stability typically occurs at that time. One could argue that adolescence ended abruptly at the age of 19. In psychology, a young adult, or lead edolesen, is considered to be between the ages of 20 and 24. Traditions typically start to transition from turbulent adolescence to more stable adulthood around this time. Therefore, even if a marriage is performed before the age of 20, as it was in Cintapuri village, the teen still feels the need to go on an adventure to discover who he is. If you get married and have kids, the wife has to take care of the kids and the husband can't leave the house because he has to go to work to learn how to take care of the family's future. As a result, there is domestic strife that leads to divorce and separation. --- Conclusions and Recommendations --- Conclusions The researcher draws a conclusion based on the findings and the discussion. Numerous factors, such as the following, contribute to the high rate of early marriage in Cintapuri Village: 1. Economic variables When a family's financial situation makes it necessary for parents to marry off their children while they are still minors in order to lessen their financial load, this is referred to as a situation where the family's financial situation is insufficient. in the hope that her child's marriage will enable her to better provide for her family. Parents and kids don't consider the negative effects of underage marriage, which will have an effect on both parties. 2. The impact of education Parents have a tendency to marry off their children while they are still minors due to the low education and knowledge levels of children, parents, and the community. Parents who only have a junior high school diploma and many who do not even attend school are not educated enough to understand the many negative effects of early marriage, and they are also unaware of the laws and regulations that govern the legal age of marriage. Additionally, parents are not overly concerned with their children's education; they do not want to send them to a university because they do not understand the value of education. --- The influence of traditions or habits. Girls without a parental companion in Cintapuri Village experience embarrassment, anxiety, and restlessness. Even if the child does not always consent, parents take part in helping their kids find friends. If it DOI 10.18502/kss.v8i12.13694 TSBEC takes too long for a family to find a partner for their daughter, sometimes quite a few people or neighbors will spread rumors about the family's condition. Parents are anxious and embarrassed about the condition. Parents still hold the mentality that if a girl is single or alone for an extended period of time, the child becomes a spinster and finds it difficult to find a partner. 4. The frequent arguments that result in quarrels between the husband and wife in their regular married lives are a negative effect of young marriage. While the impact on parents or their respective families is that if there is a disagreement or argument between a husband and wife, typically each parent is involved in settling disagreements and indirectly strains their relationship. 5. The issues that young married couples face, such as egotism within the couple and the occurrence of arguments between husband and wife, which can lead to divorce and affect not only the relationship between the couple's parents but also how closely they are knit together. --- Recommendations Researchers put forward several suggestions including: 1. For the neighborhood and youth Since education has such a significant impact on life, it is crucial that the local community is aware of its significance. Those who want to carry out underage marriages are first thought about with common sense and considerations in terms of advantages and disadvantages because marriage is to realize marriage, namely to form a happy and eternal family or household based on God Almighty . --- For parents The idea that early marriage does not always lessen the financial burden of parents is explained to parents. Parents advise their children on the value of education for the future and urge them to pursue further education rather than rush into marriage before they are emotionally and physically prepared. --- To Benefit the Government In order for those who wish to marry underage children to think twice about doing so, the government must be seriously committed to upholding applicable laws regarding underage marriages. The government should work with the office of DOI 10.18502/kss.v8i12.13694 --- TSBEC religious affairs to help village officials spread awareness of Marriage Law No. 1 of 1974 so that parents will understand it. encouraging those with traditional mindsets to approach marriage logically and realistically.

In this modern era, child marriage still remains a practice in some regions. This phenomenon damages the normal life of families and negatively affects the human capitals of Indonesia. Higher number of child marriages would lead to increase in the divorce rates than normal, as those involved in this marriage have not developed the necessary emotional control for solving problems that might arise during these marriages. This led many to the path of divorce. The goal of this research is to understand the factors that led to child marriage in Cintapuri Village, Banjar Regency, Banjarmasin. This research uses the qualitative descriptive method with phenomenological model. Subjects in this research were teenage girls married in the age of 14-16 with Junior High School (SMP) being their last education level, parents, and village governance apparatus in Cintapuri Village, Banjar Regency, Banjarmasin. The data from this research was collected through careful observations and interviews with people related to the research's objective. The result of this research shows there are several factors leading to the rampant cases of child marriage, such as economical, educational, and cultural factors. Looked through from an economical point-of-view, many parents are marrying their children off to alleviate their economic burden. From an educational point-of-view, many parents are not aware of the adverse effects of child marriage and the laws that regulate the minimum age of marriage, because of the lack of education. From a cultural point-of-view, parents are feeling nervous and ashamed for the fact that their daughter do not have a partner yet, leading them in search of a suitable partner for their daughter even though their daughter do not always approve of the parent's suitable partner.

Background Under-five mortality inequalities hamper the achievement of Millennium Development Goal 4 [1,2]. Since progress toward MDG4 is summarized by national averages, the differences in child survival among socio-economic, regional, gender, and ethnic groups may be overlooked. Neonatal deaths represent an increasing proportion of mortality in children under the age of five years, in addition to deaths caused by pneumonia, diarrhea, and malaria [3]. Almost all of these deaths occur in low-and middle-income countries . To reach MDG4, countries should maintain an annual average reduction in mortality of at least 4.4% [3]. Most LMIC in sub-Saharan Africa have not yet achieved this level and may not reach the goal at the current pace. However reducing under-five mortality inequalities is feasible and can accelerate progress towards MDG4 [4]. There are great variations in child survival within and among LMIC [5]. Ghana is one of the countries in sub-Saharan Africa that has shown rapid progress towards reaching MDG4 [6]. A regional analysis in Brazil found that, although there were social inequalities in child survival, some of the poorest regions had succeeded in reducing under-five mortality faster than the national average [7]. In Latin America, the under-five mortality rate has declined from 54/1000 to 23/1000 between 1990 and 2010 [3]. Although the region is on track towards achieving MDG4, progress has been uneven, a consequence of social inequality among the countries. Nicaragua is scheduled to reduce under-five mortality by two-thirds between 1990 and 2015 [8]. Our previous study using data from a Health and Demographic Surveillance System showed that León is improving in child mortality combined with increasing social equity in survival [9]. National surveys have indicated that the AARR among the seventeen Nicaraguan departments that constitute the country's administrative-political territory ranged from -1.4% to 15% between 1998 and 2006 [10]. If these rates continue, MDG4 may not be reached by twofifths of the departments. Our aim was to examine under-five mortality trends with regard to social and regional inequalities in two areas where population-based data is available from HDSS. --- Methods --- Study setting The municipality of León and the Cuatro Santos area are located in the Nicaraguan Pacific region. León is 93 kilometers and Cuatro Santos 250 kilometers from the capital, Managua. León is 80% urban and has a population of 172,000. Cuatro Santos is a rural area divided into four municipalities with a total population of 25,000. Agriculture and animal husbandry predominate in rural areas, while a labor market characterizes the urban areas. In 2002 of 132 municipalities, the human development index averaged 0.745 in León , compared to 0.524 in Cuatro Santos [11]. --- Health services The Nicaraguan health system includes public and private services [12]. The former consists of hospitals, health centers with general practitioners and nurses, and smaller health centers. Hospitals also have specialists on their staff. Private clinics are found only in the cities and their services are sold to the public or contracted by the Nicaraguan Social Security Institute. The municipality of León contains a teaching hospital, three main health centers, and 23 smaller health centers. Cuatro Santos has four larger health centers and nine smaller health centers, with the closest hospital 130 kilometers away. --- Surveillance site description and study design The León HDSS includes a baseline survey performed from 2002 to 2003, which contained a sample of 55,000 inhabitants . This was updated once in 2004 and twice in 2005. More information on the León HDSS can be found elsewhere [9,13]. The rural Cuatro Santos HDSS was established with a baseline survey in 2004, followed by updates in 2007 and 2009. It consists of 5,000 households. In Cuatro Santos the HDSS covered 100% of the study population. Information on vital statistics , reproductive histories of women 15-49 years, and data on household characteristics was collected from these open cohorts in both areas. Both HDSS are only representative of the urban and rural areas of the Pacific region of Nicaragua. --- Data collection Female interviewers collected data on births and deaths of children under the age of five years by taking histories of women who were of reproductive age . The birth histories of mothers who migrated out from the study area were not updated. Causes of child deaths were ascertained by means of a standard verbal autopsy interview based on the World Health Organization and the International Network for the Demographic Evaluation of Populations and Their Health recommendations [14]. The generic VA questionnaire was translated and adapted to Spanish, and three physicians in León and two physicians in Cuatro Santos independently interpreted the obtained information in order to ascertain causes of death according to the International Classification of Diseases, 10 th edition. The VA surveys were conducted in León in 2009 and in 2010 in Cuatro Santos for all deaths that had occurred after the baseline survey in the two study areas. --- Definitions The under-five mortality rate was defined as the number of deaths before the reaching the age of five divided by the number of live births for the same time period. The AARR was defined as the percentage of mortality reduction that is reduced on average in one year. Maternal education was categorized as either completed primary school or beyond or not completed primary school [15]. The fertility rate was defined as children per woman of reproductive age . --- Statistical analysis The annual U5MR was calculated from 1990 and 2005 for León and from 1990 to 2008 for Cuatro Santos. To reduce random variations in the time series, we smoothed the mortality rate trend using a three-year moving average and this average was assigned to the second year. To compute the AARR, we used the proposed measure average annual percent change taking into account the autocorrelation in the time series. We will use AARR and AAPC interchangeably in this study. It assumes a nonlinear trend of the U5MR over the study period. The AAPC is based-on segmented partitions of the time series and computed as a weighted average of slope coefficients. The AAPC is defined as: AAPC ¼ X kþ1 j¼1 ω j β j ! -1 where 'exp' is the exponential e = 2.71, 'ω' is the weight which is equal to the number of time points within each segment, 'k + 1' is the number of segments, and 'β' is the slope of the regression line in each segment of time [16]. Progress towards MDG4 was assessed as on track, insufficient, or no progress made. On track indicated that U5MR was < 40 child deaths per 1000 and AAPC at least 4.0%; insufficient was U5MR > 29 deaths per 1000 and AAPC between 0.9% and 4.0%; and no progress was U5MR > 29 deaths per 1000 and AAPC < 0.9% [17,18]. The expected U5MR by 2015 was computed with the formula: U5MR 2015 ¼ U5MR b à 1-AARR ð Þ 2015-b [19] We set a constant AARR at 4.4% to project the expected U5MR by 2015, using 1990 as the base year. Furthermore, we projected the U5MR 2015 replacing the AARR with the observed AAPC and taking the last year of the smoothed mortality trend as the base year. The number of child deaths and cause-specific fractions were measured by cause and setting. Pearson or Fisher Chisquare was analyzed and p < 0.05 considered significant. Social inequality was assessed comparing the U5MR by maternal education levels in León and Cuatro Santos. The mortality ratio and mortality differences with 95% confidence interval were calculated for this purpose. The category of references was the child mortality in mothers with completed primary education or more. Furthermore, we performed a Cox regression with robust standard errors between the level of education of the neighborhood relative to the level of education of the mother and under-five mortality for three time periods: 1990 to 1994, 1995 to 1999, and 2000 to 2005. The model was adjusted for maternal age, parity, and study setting . The hazards ratio with its respective 95% confidence interval represented the mortality gap between the two levels of maternal education. Analyses were performed in Stata 12.0 and the calculation of the average annual percent change was done with the Joinpoint public software regression program 4.0.4 . --- Ethical considerations The ethics committee at the Autonomous National University in León, Nicaragua, has given its approval to the HDSS and for the use of the data for this study in León and Cuatro Santos as part of a doctoral research project by WP during the period 2008-2012. Permission to use the dataset for this study was obtained from the coordinators of the HDSS in León and Cuatro Santos. Informed verbal consent was obtained from each person interviewed regarding cause of death. --- Results Table 1 describes demographic and household characteristics for the three settings at baseline. Urban León had the lowest fertility rate, followed by Cuatro Santos and rural León. The proportion of women with completed primary education was higher in urban León than in the two rural settings. However, primary education level and presence of latrines was higher in rural León than in Cuatro Santos, and Cuatro Santos also showed a higher level of poverty when compared to León. A total of 24,385 births were recorded in León from 1990 to 2005, and a total of 12,879 births in Cuatro Santos from 1990 to 2008. The number of under-five deaths in urban León, rural León, and Cuatro Santos were 446, 313, and 408, respectively. The U5MR declined in all three settings during the study period . The U5MR declined about twice as much in urban León, as in rural León and Cuatro Santos. Rural León showed an almost linear decline, but urban León had a faster reduction from 1991 to 1995. Then, from 1997 to 2001, the U5MR increased, experiencing another reduction after 2001. Cuatro Santos had more variable trends with ups and downs in different time periods. The initial reduction was during the first three years of the study period, and then it increased until 1997. A reduction was observed for the next four years like in the first period, and finally a short increase was observed between 2001 and 2004 followed by a slow reduction by 2007. Urban León is the setting with the highest observed AAPC. Between 1990 and 2005, rural León showed a higher AAPC than rural Cuatro Santos . The three settings are on-track to achieve the MDG4 target by 2015. With the observed AAPC urban León may surpass the target; meanwhile the rural settings might reach an expected U5MR sufficient to achieve the MDG4 target with the observed AAPC. Table 3 shows the social inequalities over time and progress towards MDG4 in each setting. In León, 35 mothers did not have primary education between 1990 and 2005. Child mortality was higher among children of mothers without primary education, except in rural León from 1990 to 1994 and rural Cuatro Santos from 2000 to 2008. In urban León AAPC from 1990 to 2005 was higher for mothers without primary education than for those with primary education or more . In contrast, the AAPC for the same years in rural León was higher in the group of mothers with completed primary education or more , than mothers with lower education level . In Cuatro Santos, the AAPC from 1990 to 2008 was similar for both levels of maternal education. Between 1990 and 1994, the highest hazard ratio of mortality occurred among children of mothers without primary education whose neighbors also had a low education level , while the lowest risk was among mothers with primary education residing among neighbors with the same education level . During the last two time periods, the association of maternal education relative to average education in the neighborhood was not significant . A total of 59 under-five deaths in León and 39 in Cuatro Santos were analyzed to ascertain the cause of death . Ten planned interviews were not performed in León ; one was not performed in Cuatro Santos . The proportion of neonatal deaths was higher in León than in Cuatro Santos . Infectious diseases after the first month of life were responsible for 22% of the deaths in León and 41% in Cuatro Santos. --- Discussion --- Main findings In three rural and urban Nicaraguan settings overall child survival had improved sufficiently to reach the MDG4 by 2015. There were, however, differences in the rate of progress. It was faster in urban León than in both rural areas surveyed, as well as in comparison with the national level [8]. Using maternal education level as a social characteristic we found that the reduction in mortality was combined with greater equity in survival not only in the wealthier urban area but also in the poorest of the three study areas. Neonatal deaths accounted for a high percentage of under-five mortality, in addition to infectious diseases, indicating a major opportunity for further improvement in child survival by implementing a high-coverage perinatal care in all areas. --- Methodological issues The possibility of recall bias in birth histories is well documented and may affect mortality estimations. To minimize such bias, local calendars were used during interviews to help the respondent to precisely remember the birthdate and the date of death of their children [9,15]. In León, information on maternal education was obtained in the reproductive survey conducted in 1996 and updated during routine visits to the same study clusters of the HDSS [9,13]. Because the small number of deaths resulted in unstable rates, we operationalized maternal education in two categories. Unfortunately, this did not allow analysis of the inequity gradient of mortality beyond this dichotomy . In Cuatro Santos this information was measured from the HDSS baseline and onwards covering the situation from 1990 in the stratified analysis of child mortality. Poverty is another measure applied in studies on inequities. Both HDSSs use unsatisfied basic needs to assess poverty [9,15]. However, for those births that occurred ten years before baseline, this measure of poverty might be unreliable. The number of deaths was small at the end of the study period limiting the statistical power in the multivariate analysis. Non-participation in the data collection was less than 0.1% in both León and Cuatro Santos. --- Trends and equity in child survival Urban León is on track to reach the MDG4 before 2015. Two different trends were observed in urban Leon. First, the rapid progress between 1991 and 1996 in comparison with rural León may be explained by higher provision of social services , easier access to health services and more resources in the households, including a higher proportion of mothers with primary or higher education. Evidence from sub-Saharan countries was not consistent with this finding, where demographic dynamics negatively impacted housing conditions, access to healthcare, and child survival [20]. Some evidence suggests that urbanization may improve child survival [21]. Second, between 1997 and 2001, the U5MR increased, a period also characterized with a high inequity gap in child survival between social groups in the urban area. It might reflect the situation of child health in periurban blocks where the population lives in a less healthy environment than in rural areas, where migrants from rural areas often settle [22,23]. However, the current data set does not allow a more detailed analysis of urbanization, poverty and child health in urban, peri-urban and rural areas, a relevant settings issue in low-and middle-income countries [24][25][26]. Although rural León is on track toward MDG4, the almost linear decreasing mortality trend was accompanied with widening inequalities. This scenario is often found in LMICs [27,28], indicating that lifesaving interventions are not reaching the most disadvantaged socioeconomic groups, or their health seeking is delayed [29][30][31]. One study in Nicaragua reported that the nearest public health service is the one most accessed by the poorest people, but these facilities lack the resources to deal with serious illness. Mothers must incur high costs in order to obtain good quality health care, often by traveling to a city [32]. Baseline mortality rate in Cuatro Santos was lower than in rural and urban León. A hypothesis is that León was one of the zones more affected by the war during the 1980s. The annual trend reveals a cyclical pattern every three or four years in Cuatro Santos. Two possible explanations may be either the presence of a random variation due to small number of child deaths or seasonal patterns. Extreme climate variability raises the pluvial level and it is associated with an increase of the incidence of infectious diseases like diarrhea and respiratory diseases, mainly affecting children. For example, outbreaks of rotavirus and leptospirosis have most affected the Pacific region of Nicaragua and likely the response of the primary and curative health services in Cuatro Santos may have been limited, in comparison to León [33,34]. The sudden increase observed between 1994 and 1997 may also be explained by a migration of refugee families that were displaced from the area during the 1980s to neighboring areas in Honduras, where they lived in precarious health conditions. After the war, that population group returned to Cuatro Santos . Studies in African contexts have found higher childhood mortality among former refugee populations in comparison with mothers that never emigrated [35]. Despite these changing trends experienced in Cuatro Santos, the poorest region in our survey, child mortality trends revealed rapid progress to reach the MDG4 combined with greater social equity in child survival over time in comparison with rural León. This is contrary to the common pattern in low-income societies, although other examples exist of similar patterns to those in Cuatro Santos [27,36]. In this area poverty is widespread but with some decline from 67% in 2004 to 55% in 2009 [37]. Investment has been made in the area, like improved roads that may improve commerce and reduce poverty and there is also improved access to health services. Improvement to the safe drinking water supply to households and sanitation has also taken place, which is essential for child health [38]. This geographical area has experienced substantial emigration that may affect economic development through the influx of remittances. One-fifth of households in Cuatro Santos have at least one family member who has migrated, mainly to Costa Rica, El Salvador, Guatemala, or Honduras [39]. Education is considered a determinant of child survival and reduction of inequalities [40]. Studies in poor settings have found that educated women are more capable of understanding health information, demanding access to healthcare services, and carrying out other health seeking behaviors than less educated women [41]. An individual's socio-economic position relative to the socio-economic position of the neighborhood may be associated with inequalities in health outcomes [42]. Peña et al. found that impoverished mothers living in poor neighborhoods experienced lower levels of child mortality compared to poor mothers living in more affluent neighborhoods [15]. The mechanism was reportedly that poor people living among other poor people might have a stronger social support network for providing resources for health than poor people living among non-poor. In our study, in which we used education instead of poverty as a socio-economic indicator, the maternal position in the neighborhood seems to have an important influence on child survival during the early years of the study. This might indicate that mothers copy the health behaviors of other people in the neighborhood, with a worse scenario for child survival when mother and neighborhood have low levels of education. Education is a form of social capital, and mothers with no primary education may not receive appropriate advice or social position to manage severe child illnesses. --- Causes of deaths In both León and Cuatro Santos neonatal causes dominated among the under-five deaths, followed by infectious diseases, especially in rural Cuatro Santos. This is a pattern found in most LMICs [43]. It should be noted that in spite of a relatively low level of mortality in comparison with other LICs, diarrhea deaths are still a problem, highlighting issues related to water and sanitation as well as access to rehydration therapy. Further analysis of neonatal causes of death may suggest possible preventive strategies within the perinatal health services in the areas. --- Conclusions The three geographical areas in our study were all on track to reach MDG4, but only two showed improved equity in child survival. The urban area with better health services and more educated mothers but also the remote rural area with only primary health care services and less educated mothers showed this favorable pattern. The rural area surrounding the city of León had sustained social inequality in child survival rates. Our findings show that reduction in mortality before the age of five years can be combined with greater equity in child survival, even in a very poor society. --- Competing interests The authors declare no competing interests. Authors' contributions EZ, RP, LÅP, and CK designed the HDSS. LE and EZ performed quality control on the data from the Cuatro Santos HDSS. WP participated in data supervision for the León HDSS. WP did the statistical analysis and wrote the manuscript. LE, EZ, LÅP, CK, and RP shared in interpreting the data. All authors read and approved the final draft of the manuscript.

Background: Social inequality in child survival hampers the achievement of Millennium Development Goal 4 (MDG4). Monitoring under-five mortality in different social strata may contribute to public health policies that strive to reduce social inequalities. This population-based study examines the trends, causes, and social inequality of mortality before the age of five years in rural and urban areas in Nicaragua.The study was conducted in one rural (Cuatro Santos) and one urban/rural area (León) based on data from Health and Demographic Surveillance Systems. We analyzed live births from 1990 to 2005 in the urban/rural area and from 1990 to 2008 in the rural area. The annual average rate reduction (AARR) and social under-five mortality inequality were calculated using the education level of the mother as a proxy for socio-economic position. Causes of child death were based on systematic interviews (verbal autopsy). Results: Under-five mortality in all areas is declining at a rate sufficient to achieve MDG4 by 2015. Urban León showed greater reduction (AARR = 8.5%) in mortality and inequality than rural León (AARR = 4.5%) or Cuatro Santos (AARR = 5.4%). Social inequality in mortality had increased in rural León and no improvement in survival was observed among mothers who had not completed primary school. However, the poor and remote rural area Cuatro Santos was on track to reach MDG4 with equitable child survival. Most of the deaths in both areas were due to neonatal conditions and infectious diseases. Conclusions: All rural and urban areas in Nicaragua included in this study were on track to reach MDG4, but social stratification in child survival showed different patterns; unfavorable patterns with increasing inequity in the peri-urban rural zone and a more equitable development in the urban as well as the poor and remote rural area. An equitable progress in child survival may also be accelerated in very poor settings.

Introduction Persons with disabilities include any person who experiences physical, intellectual, mental and sensory limitations for an extended period. Moreover, in interacting with the living environment, PwD may experience obstacles and difficulties in participating fully and effectively with other citizens on an equal rights basis. Types of PwD include physical disabilities in the form of impaired movement functions, as well as intellectual disabilities in the form of challenged thinking functions due to below-average intelligence levels . The number of PwD is quite large, with more than 1 billion of the world's population having a disability . In Indonesia, the number of PwD is 12.15%, and only 51.12% participate in the workforce . PwD often experience discrimination in the health sector , education , the economy , and the law . Discrimination against PwD results in poor health services, lowquality education, reduced job prospects and limited social participation. Empirically, PwD can excel in various fields up to the international level. This success aligns with a shift in the disability paradigm from a 'traditional model', which is voluntary , to an 'individual model-medical model' emphasising rehabilitation assistance . This model then becomes a 'social model' focusing on services for community change . Ultimately, the community's mindset must be changed. In addition, the accessibility of PwD to activities in various developmental fields is vital . Implementing an 'inclusion model' by bringing PwD into social life to accommodate their human rights is essential . With ratifying the UN Convention on the Rights of Persons with Disabilities in 2011, the Indonesian government is working hard to eliminate discriminatory practices against PwD. Although much research has been conducted on PwD, the novelty of this study lies in its application of the penta helix approach for PwD. Research on PwD includes identifying forms of government legal protection to fulfil the right to work for PwD in Indonesia and knowing how to create an inclusive work environment for PwD in Indonesia . Kim and Zhu wrote about enhancing social inclusion for people with physical disabilities seen from the role of mobile social network applications by disability support organisations in China. In another work, Maini and Heera explored disability inclusion in organisations through a managerial lens. In 2015, Simplican et al. explained the definition of social inclusion for persons with intellectual disabilities and its development in terms of the ecological model of social networks and community participation. Meanwhile, Haug examined inclusive education both ideally and in reality. Little et al. investigated social inclusion from the perspective of students with disabilities, particularly regarding issues of friendship and acceptance. Loneliness in life stories by PwD was examined by Tarvainen . Additional research includes a study on designing an accessibility portal for a higher education institution , and challenges and solutions in recruiting and retaining PwD for qualitative health research . Studies on the penta helix model or using the approach have been carried out by several researchers, including Wisudayati et al. , who researched the implementation of the penta helix collaborative model in developing the potential of government agencies as public service agencies. Maturbongs and Lekatompessy examined the penta helix collaboration in the development of local wisdom-based tourism. Castañer and Oliveira and Chamidah et al. describe the synergy of penta helix elements as an effort to develop tourism villages in Indonesia. Halibas et al. examined the penta helix innovation model and Sudiana et al. scrutinised the development and validation of penta helix construction. Subagyo analysed the implementation of the penta helix model for the terrorism deradicalisation programme in Indonesia. Additionally, Garcia and Cater examined the challenges for tourism partnerships in achieving ocean literacy. The seven studies above discussed the inclusion of PwD from economic, educational and health perspectives. Meanwhile, research on the penta helix discussing the development of social inclusion models for PwD has never been carried out. This study examines collaboration between stakeholders in developing social inclusion for PwD from the penta helix perspective, namely collaboration between government, community, academia, business or entrepreneurs and the media. More specifically, this research aims to understand the five links in the penta helix collaboration in supporting the development of social inclusion in disability management. The penta helix collaboration occurs between the government as political power, the community as social power, academics as knowledge power, entrepreneurs as supporters of social justice power and the media as expanders . --- Research Methods Research was conducted in the city of Surakarta because the city has been driven since 2017 to become one of the models of a disability-friendly city in Indonesia. In 2022, Surakarta was designated as the organiser of the Asian Para Games 2022. Consequently, Surakarta is considered to have a legacy as a disability-friendly city. In addition, Surakarta has been designated as a national training centre for athletes with disabilities. Surakarta's success in hosting the Association of Southeast Asian Nations Para Games 2022, attended by 11 Southeast Asian countries, proves that Surakarta has collaborated among stakeholders, making it attractive for further research. The research is descriptive and qualitative. Data were collected through observation, focus group discussion and documentation. Research informants were determined purposively from penta helix representatives who were seen as understanding or having experience or expertise in disabilities. The research informants included Elements of the Surakarta City government, including the head of the Social Rehabilitation Division of the Surakarta City Social Service; the head of the Surakarta City Social Service Planning and Budgeting Sub-Coordinator; the Surakarta City Labour Office and the Surakarta City Disabled Advocacy Team. Community representatives, including the chairman of the Surakarta City Branch Leadership Council of Gerakan Untuk Kesejahteraan Tunarungu Indonesia , the Yayasan Pembinaan Anak Cacat , and Difa Sukses Mandiri. From academia, the head of the Centre for Disability Studies at Universitas Sebelas Maret was included. For entrepreneurs, the PT. Tiga Serangkai Pustaka Mandiri company was selected, and from the media, the following organisations were selected: solopos.com, genpi.co, radarsolo.jawapos.com, suaramerdeka.com and antaranews.com. The analysis technique follows the model by Miles et al. , and was carried out in three stages: data condensation, data presentation and forming conclusions. Data condensation involves sorting, focusing, simplifying, abstracting and transforming data from written field notes, interview transcripts, documents and other empirical materials . In this process, researchers select and summarise important data without changing meaning, focusing on sharpening data, looking for similar patterns and grouping data to then conclude at the end. --- Figure 1. Interactive Model Data Analysis Source: Miles et al. After data condensation, the next stage is data presentation. The data are revealed by grouping previously selected and sorted data at the condensation stage to conclude . Data are presented by describing and connecting categories and then creating narrative text. The next step is concluding and verifying. Initial conclusions are temporary, which may change when going to the field to find other, more substantial evidence. When the conclusions made at the beginning are the same as the conclusions and are supported by valid evidence, the results obtained are quite credible. The stages of data analysis are depicted in Figure 1. --- Data Collection Data Display --- Data Condensation Conclusions: drawing/verifying --- Results and Discussion 'Collaboration' is a term describing a pattern of cooperative relations carried out by more than one party . The basis of collaboration is the principle of togetherness, cooperation, sharing of tasks, equality and responsibility . Collaboration is joint involvement in a coordinated effort to solve problems together. Characteristics of collaborative interactions include common goals, a symmetrical structure with high-level negotiations through joint activities and interdependence . Collaboration is not limited by a particular time or period -it is still needed if affairs have an allusion or intersection with other parties. Collaboration involves several parties, starting from the individual level, work groups and the organisation . Note that collaboration has a protracted timeframe. As a process, collaboration is an ongoing interaction between several people. In conducting collaboration, joint planning is needed so that its implementation becomes a shared responsibility. This view aligns with scholars indicating that collaboration is a complex process requiring knowledge-sharing that is planned, intentional and a shared responsibility . In essence, collaborators aim to achieve common goals by helping each other. The purpose of collaboration is to accelerate the achievement of goals together. Even in reaching these goals, it is inadvisable to compartmentalise the tasks in charge. In this study, collaboration was carried out by the government, the community, businesspeople, universities and the mass media. --- Government as Political Power In carrying out its role as political power, the Surakarta City government has proclaimed itself a disability-friendly, socially inclusive city since 2010. Surakarta, which identifies itself as a city friendly to PwD, has substantiated this assertion through the enactment of several legislations, including Regional Regulation Number 2 of 2008 concerning disability equality, Mayor's Regulation Number 9 of 2013 for implementing this equality law, Regional Regulation Number 9 of 2020 for the protection of PwD rights, and the Mayor's Decree of 2021 regarding social assistance for the elderly and PwD. These regulations are the basis for the Surakarta City government in developing various activities that provide benefits for PwD, such as Mobile Social Service Units, Providing additional food for PwD, social rehabilitation and collaboration with organisations working in the disability sector, such as the Disability Advocacy Team and YPAC. At the Mobile Social Service Unit, the Surakarta City government collects data on disability needs according to type. Next, recommendations for mobility assistance or hospital referrals are provided for people with disabilities. The Surakarta City government is also developing a Programme for Providing Additional Food for PwD per their disability criteria every three months. The Surakarta City government has also developed a social rehabilitation programme for people with physical disabilities at the Bina Daksa Prof. Dr. Soeharso Surakarta Social Rehabilitation Centre. In addition, the Surakarta City government is collaborating with the Disability Advocacy Team and YPAC. The research findings show that the government acts as a political force through the development of policy and product innovations. This view aligns with Bartley , who maintain that the government acts as a regulator with political power that produces regulatory policies and encourages innovation. Regarding social inclusion, policy innovation is manifested by regulating social inclusion services and encouraging product innovation by building physical infrastructure and providing facilitators for PwD. --- Society or Community as Social Power The Branch Leadership Council of GERKATIN in Surakarta City is a unique community for the deaf. One of the activities of the Leadership Council of the GERKATIN Branch in Surakarta City is to make classes a place of learning for the community, especially the deaf , to broaden their horizons and improve their abilities so they can understand the culture of deaf friends and self-development for deaf friends. Aimed at deaf friends and the general public, one of the classes offered is Bahasa Isyarat Indonesia . Surakarta City has a community for PwD, namely Difa Sukses Mandiri and Persatuan Tunanetra Indonesia Surakarta. DSM is a community-based enterprise with disabled members. The community objectives of DSM are to create independence, economic welfare and improve quality of life by increasing competence, self-confidence and workforce opportunities for PwD. The collaboration between DSM and the Surakarta City government includes outreach and training for PwD in cooking, sewing, workshop training, IT training and family financial management. In addition, training is provided by social institutions regarding advocacy and the protection of children and women with disabilities. PERTUNI is a national-level blind community-based organisation. The PERTUNI Surakarta City Branch has 35 active members. PERTUNI's goals are to create conducive conditions for blind people to carry out their lives as individuals and citizens who are intelligent, independent and productive without discrimination in all aspects of life and livelihood. The form of collaboration by PERTUNI and the Surakarta City Government includes consolidating efforts to encourage open access to facilities and support for disabilities regarding financial assistance. PERTUNI also works with the Komisi Pemilihan Umum and Badan Pengawas Pemilihan Umum BAWASLU; General Election Supervisory Body) Surakarta City regarding the accessibility of election facilities and providing input regarding election venues, ballot cards and braille templates. This work's findings show that the community acts as a social force by developing cohesiveness among PwD, enabling the development of a disability self-concept and serving as a facilitator between universities, the business world, government and the media. This social force is shown in the community by facilitating forums, conducting social activities, disseminating regulations on disabilities, evaluating needs and offering skills training for PwD. Society as a social force can be achieved through public values based on deliberative thinking without isolating certain groups . These public values must come from the social collectivity of people who act together in the public space accompanied by democratic dialogue about common interests. --- Academics as Knowledge Power Universitas Sebelas Maret is one of the universities in Surakarta with a focus on PwD. UNS implements a disability-friendly policy and does not discriminate against PwD. As an inclusive tertiary institution, UNS continues to provide equal space for PwD to participate in the selection to enter tertiary institutions with various entry routes and supporting facilities. UNS has a Center for Disability Studies, which is expected to become a centre of excellence for science and technology, realising UNS as an inclusive tertiary institution in 2024. The Center for Disability Studies also collaborates with domestic and foreign agencies. UNS has established standards for education quality service, which include student service standards as part of education quality, adherence to inclusive campus standards, acceptance of disability-independent pathways, compliance with Law Number 8 of 2016 as per the UNS Chancellor's Decree, and the promotion of an inclusive campus through the development of the Inclusive Campus Index instrument, aimed at enhancing UNS's higher education ranking in 2022. Collaboration between the Center for Disability Studies and its partners includes expanding access to education together with the National Commission on Disabilities, as well as digitalisation in developing applications for improving teacher technology, and Cooperation with the central government, namely conducting training for teachers in regular schools for inclusive education competencies. Academics play the role of knowledge power by developing innovations to improve disability access and conducting studies to support disability self-development. As Muhyi and Chan submit, academics are a source of knowledge in the penta helix, with concepts and theories for developing businesses to gain a sustainable competitive advantage. --- Entrepreneurs as Supporters of Social Justice Power Based on the results of interviews with the Surakarta City Manpower Office, private companies are required to employ at least 1% of PwD from the number of employees or workers by the provisions of Article 53 of Law Number 8 of 2013. However, this requirement still needs improvement and implementation due to a need for more applicants. In addition, the limited skills and competencies possessed by PwD make it difficult for them to obtain job opportunities according to the needs of the labour market. One of the triggers for PwD to be reluctant to apply for jobs is the addition of a requirement to possess a competency training certificate. Moreover, the private sector and industry consider that accepting PwD as workers will hinder company performance. A disability-friendly work environment has not yet been implemented, which is the reason it is difficult for PwD to get jobs even though companies that do not implement the 1% policy on disabled workers will receive sanctions. Although only a few companies accept workers with disabilities, Tiga Serangkai Pustaka Mandiri is one of the private companies in Surakarta City that provides opportunities and attention to workers with disabilities. This company received an appreciation award for employing three employees with disabilities. One of the programmes from the Mandiri Libra Triad is spiritual building training. The programme aims to increase the spiritual intellect of trainees, most of whom are PwD. Collaborations between the Surakarta City government and entrepreneurs in Surakarta City include providing business capital assistance to 10 PwD through the Sufism programme, namely cash assistance of two million rupiahs, and work skills training for PwD. The Surakarta City government has appointed 11 companies that accept employees with disabilities. The programme is called 3 in 1, which consists of skills training, certification and job placement for PwD. The industrial companies that cooperate in this programme are the garment, textile and footwear industries because these industries are considered able to absorb the most labour. This work shows that entrepreneurs play a role as a force for social justice through providing employment opportunities for PwD and corporate social responsibility for developing the quality of life of PwD. The activities include business capital assistance and work skills training for disabled persons. The role of entrepreneurship as a force for social justice is in line with the opinion of Jabeen et al. , where the industry creates entrepreneurship participants, products, technology and drivers of innovation in accelerating change. --- Media as an Expander The media not only chooses events and determines news sources but also plays a role in compiling and defining the reality of various events that occur. Through this process, information becomes helpful for the public and can determine how people see and understand events. Generally, the mass media does three things when forming public opinion. First, the media uses symbols to generate recognition. Second, the media carries out a message packaging strategy . Third, the media sets the agenda to determine the priority of which messages are conveyed to the audience . Disability issues are often considered trivial, unimportant and uninteresting to discuss . The media often misrepresents disability issues, which creates stereotypes in society that affect social positions and public policies regarding the fulfilment of the rights of PwD . Five online media outlets were used in this study, namely solopos.com, genpi.co, radarsolo.jawapos.com, suaramerdeka.com and antarnews.com. News from the five online media outlets is seen from the perspective of the needs of PwD in Surakarta City in 2018-2022. Figure 2 illustrates the number of disability-related issues published in daily newspapers, with the highest number being reported by Antara News. Antaranews.com is the media outlet in 2018-2022 containing the most issues on the needs of people with disabilities, amounting to 224 news items. Meanwhile, genpi.co at least raises the issue of disability needs in 16 stories. Based on a content analysis of media coverage, it was found that news coverage about services for PwD was either positive or negative. Positive information about trials of disabled-friendly buses with low deck models and facilities for the blind and walking letters that make it easier for the deaf. Criticism of employers who set high standards and negative stigma for PwD so that their accessibility to get jobs is hampered. Positive appreciation for the government, which protects persons with disabilities using traditional markets. Criticism of the Electric Rail Train service provider agency , which refused to allow the disabled to board the KRL because it was not in accordance with procedures. Criticism of the behaviour of people who misuse sidewalks for PwD as a place to trade. Table 1 indicates that the media is advocating through sharp criticism or appreciation of the government, employers or the public so they are non-discriminatory and more responsive to the needs of PwD. The media is also a bridge to influence policymakers in formulating policies responsive to the interests of PwD. The media play the role of expander by promoting social inclusion for PwD and encouraging the formation of disability-friendly villages. This promotion role is echoed by Muhyi and Chan , who claim that the media is the stakeholder with a vital role in promoting and developing business. The activities carried out by the media include conducting policy advocacy on disability issues and influencing lawmakers in formulating strategic policies that ensure disability rights. The overall relationships in the penta helix regarding social inclusion for PwD are depicted in Figure 3. --- INNOVATION The penta helix collaboration model in social inclusion clearly illustrates that the government as a political power develops policy and product innovations that provide facilities for PwD. Furthermore, society as a social force develops public values without isolating certain special-needs groups . Academics as a knowledge power develop businesses to gain a sustainable competitive advantage by developing an inclusive campus. Meanwhile, entrepreneurship as a social justice power provides job opportunities to develop the quality of life of PwD. Finally, the media acts with the power of brand image, promoting the paradigm of social inclusion for PwD and encouraging the formation of disability-friendly villages. Furthermore, the media influences policymakers to view fulfilling disability rights as a strategic policy issue. This collaborative model complements previous studies that have not explicitly discussed PwD. --- Conclusion This study revealed a penta helix collaboration between the Surakarta City government, the community, academics, entrepreneurs and the media in developing social inclusion for PwD. In this collaboration, the government plays a role in exercising political power through its issuance of Regional Regulation 9 of 2020 concerning the protection and fulfilment of the rights of PwD with the aim that PwD get the same rights and opportunities as other citizens. The community has a role as a social power by creating care classes for PwD so that people understand the culture and self-development of PwD. Academics serve in a knowledge power function by developing campus inclusion standards and collaborating with national and international funding institutions to carry out the three pillars of higher education in Indonesia on the issue of PwD. Industry functions as a social justice power in supporting the provision of venture capital assistance and work skills training for PwD. Lastly, the media holds the power of brand image so that discriminatory views against PwD turn into fulfilling the rights of PwD. Understanding stakeholders' roles in the penta helix collaboration helps develop a social inclusion model for PwD.

This research examines collaboration between the government, community, academia, entrepreneurs and the media, known as the 'penta helix', in developing social inclusion for persons with disabilities (PwD) in Indonesia. This descriptive and qualitative study collects data through observation, focus group discussions and in-depth interviews. The research informants were determined purposively from representatives of the penta helix who were seen as understanding or having the authority to interact with PwD. For data analysis, Miles and Huberman's interactive analysis model was employed. Regarding the five areas of the penta helix, the study found that the government exercised political power through the issuance of Regional Regulation 9 of 2020 concerning the protection and fulfilment of the rights of PwD. The regulation aims to ensure that PwD receive the same rights and opportunities as other citizens. The community has a role as social power through creating care classes for PwD for people to understand the culture and self-development of PwD. Academics function as a knowledge power by developing campus inclusion standards and collaborating with national and international funding institutions to carry out the three pillars of higher education on the issue of PwD. Industry plays a role as social justice power in supporting the provision of venture capital assistance and work skills training for PwD. The media holds the power of brand image so that discriminatory views against PwD transform into fulfilling the rights of PwD. Understanding stakeholders' role in the penta helix collaboration helps develop a social inclusion model for PwD.

Background Marriage is a major protective factor for adult wellbeing [1]. Conversely, major conflict in the couple relationship is associated with negative mental health and wellbeing outcomes [2]. For instance, couple conflict predicts a higher incidence of mental disorders in adults, as well as negative social outcomes [2]. The quality of the couple relationship is thus a critical factor in adult mental health and wellbeing. Extending from the couple unit, we note that families have long been viewed as the stable building blocks of society, playing a key role in nurturing, supporting, and socialising children [3]. However, major societal changes over past decades have been associated with changes to the longevity and diversity of family structures [4]. While most adults aspire to live in committed couple relationships and can expect their total married life to endure for an average of 32 years, the divorce rate now stands at 2.3 divorces per 1,000 population in Australia [5]. In 2011, 48% of divorces involved children under the age 18 years. This equates to approximately 50,000 children a year experiencing the divorce of their parents [6], with potentially serious negative long-term consequences for children [7]. Earlier meta-analyses reported that children of divorce had poorer academic achievement, conduct, psychological adjustment, and social development than children from intact families [7]. Recent studies have linked parental divorce with an increased risk of suicide attempts [8,9] and poor mental health [10]. Despite the heightened risk associated with parental divorce, it is important to note that the majority of children experiencing divorce do not experience long-term negative consequences [11], and researchers are increasingly interested in exploring the concept of resilience in relation to negative life experiences. Nevertheless, one documented risk factor for poorer outcome following family separation is ongoing or high-level parental conflict which has been associated with increased emotional instability, academic problems, behavioural and psychological stress, and uncertainty in children [12][13][14]. Conversely, the interests of children in separated families seem to be best served when parents are cooperative, child focussed, and reach formal agreement about their separation without litigation [12,15]. --- Parental conflict The process of separation is unique for each family, but commonly involves a period of heightened anger, anxiety and sadness, followed by positive readjustment after two to three years [16,17]. However, up to a third of separated couples are unable to settle their child-related issues [18], and for this subgroup, the conflict lasts longer and brings heightened risks for future well-being for themselves and their children [19]. High conflict associated with family breakdown also presents a serious challenge to achieving separation and child custody agreements as "primitive responses are triggered in parents poised to protect their children" [20]. Not only can conflict escalate into more serious forms of destructive behaviour, but can lead to parental disengagement and increased likelihood of negative outcomes for children, such as reduced cognitive competence [21]. The impact of marital conflict and hostility on children is increasingly understood as multi-dimensional, with particular aspects or styles of marital conflict accounting for specific adjustment problems in children [22,23]. Early studies found that important determinants of the effect of conflict on children included the form of the conflict , the content of the conflict and the amount of inter-parental conflict [21]. Substantial research has supported links between elements of marital conflict and specific patterns of marital communication, such as less facilitative and more aggressive behaviour [24]. Destructive communication, such as throwing insults or bringing up events from the past, breeds marital dissatisfaction in the face of life challenges [25], and is a strong predictor of divorce in the longer term [26]. Future research needs to include more differentiated measures of the types and severity of conflict to advance our understanding of the process and impacts of family breakdown, and how it can best be managed through services such as family mediation. --- Family violence One area of particular concern is when parental conflict involves family violence, since the negative impacts of parental conflict are heightened when family violence is present. Domestic violence has emerged as one of the world's most pressing issues, with the United Nations estimating that between 20% and 50% of all women worldwide have experienced physical violence at the hands of intimate partners or family members [27]. An estimated one in three Australian women have experienced family violence during their lifetime [28], making it a major health risk to women [29]. Children's exposure to family violence or abusive behaviour is also of concern, with estimated rates varying from 10% to 50%, depending on samples and data source. For instance, a national US survey found that almost 10% of children saw one family member assault another [30]. In Australia, the 2005 Personal Safety Survey estimated that almost half of the men and women who had ever experienced violence by a current partner, had children in their care at the time [28]. As well, more than a quarter said that these children had witnessed the violence. The definition and understanding of family violence has been subject to much debate [31,32]. Since the early 1990s, it has been acknowledged that single-factor explanations are inadequate and researchers have found it helpful to develop more differentiated typologies of family violence [15,31,33]. Recent amendments to the Family Law Act in Australia define family violence as a range of behaviours including: physical assault, harassment, emotional manipulation, financial abuse, and threatening behaviour [6]. Others have differentiated between various patterns of family violence [34]. For instance, Johnson identified four types: 'common couple violence' which arises from a specific incident and is not likely to escalate over time; 'violent resistance' refers to a woman fighting back at her aggressor; 'mutual violent control' where both partners are violent; and 'intimate terrorism' where the violence is part of a general pattern of control and is likely to escalate over time, is less likely to be mutual, and is more likely to result in serious injury. Johnson also differentiated types of violence by the motivation of aggressors [34]. The most common form was situational violence involves partners reacting in the moment, but without an ongoing pattern of controlling behaviour. Another more serious form is an ongoing pattern of coercive controlling violence involving threats and intimidation and curtailment of personal freedoms and rights of the partner, what Johnson referred to as "intimate terrorism" [26]. Situational couple violence was found to account for 89% of violence in one survey, and coercive controlling violence accounted for 11% [35]. However, in relationships where intimate terrorism occurs, the violence has been found to occur more frequently and more severely than with situational violence [26]. Johnson's work has been criticised because of its emphasis on physical violence and there is now increasing focus on differentiating among non-physical types of family violence such as psychological, emotional, social, and economic abuse [31,36]. Psychological abuse has been defined as: emotional/verbal abuse distinguished by devaluing or humiliating behaviours; and dominance/ isolation which intends to produce compliance or conformity [31]. Economic or financial abuse is a form of non-physical violence and involves preventing a partner from knowing about or having access to family income. Non-physical forms of abuse are far more prevalent than physical abuse but there is increasing evidence that nonphysical abuse can be a strong predictor of physical violence [37]. There is growing recognition of the need to also differentiate forms of violence by severity [31,37]. Moderate physical violence is described as serious but not life threatening behaviour such as pushing, grabbing, slapping, shoving. Severe physical violence includes threats using weapons, hitting with a fist or object [31]. This line of research is part of a growing call to move away from a simple present/absent approach to violence, and to take a more contextual view [36]. Gender is an important variable in any study of family violence. Generally, the most persistent and controlling forms of violence, such as 'intimate terrorism' , are perpetrated by men, whereas more situational forms of violence are more likely to be instigated by both men and women [34,38]. However, gender differences are hotly debated. Despite strong evidence that most domestic violence is perpetrated by men against women, there are also now more than 100 empirical studies or reports suggesting that rates of domestic violence are equivalent. Therefore, future research on family violence needs to be gender-inclusive [39]. A number of methodological difficulties challenge our understanding of this social problem. Different studies have relied on different conceptualizations of aggression in families and use different sources of data, different age relationship status groups [40]. For example, studies of clinical samples tend to oversample severe forms of deliberate coercive male-driven violence, whereas studies using population-based samples or smaller studies of couples seeking marital therapy, may have downplayed the role of control by including many relationships characterized by violent arguments [39,41]. A key methodological issue is inconsistency in the conceptualization and measurement of couple conflict and family violence. The Conflict Tactics Scale [42] has been widely used in research to measure the extent to which specific acts of violence have been enacted by both oneself and one's partner, and to quantify severity as a sum of different types of violent acts. It comprises subscales measuring negotiation, psychological aggression, and physical assault, and distinguishes between minor and severe acts. The Conflict Tactics Scale Revised [32] included two additional scales , and some additional items in other subscales. The CTS and CTS2 have been criticised on a number of levels, and researchers frequently modify it to meet the needs of particular studies [39,[43][44][45]. At the very least, it has been argued that this scale should be supplemented with measures that tap additional aspects of violence and the contexts in which it occurs [26,43]. This is particularly the case to advance our understanding of the nature and impact of different forms of family violence within the family mediation context. --- Family violence and parental separation Relationship breakdown and couple separation presents a critical period in the family violence cycle. Parental separation rarely means an end to violence since, for women in abusive relationships, the separation phase is the time of greatest risk of partner violence and homicide [46][47][48]. An analysis of Family Court of Australia cases found that violence was a factor in 75% of judicially determined cases [49]. In a later Australian Institute of Family Studies study of family violence allegations in the family courts, two thirds of separated mothers and over a half of separated fathers indicated that their child's other parent had emotionally abused them before or during the separation [40]. The main forms of abuse were: physical violence , threats , emotional abuse and verbal abuse . However, a key limitation of this research was its focus on simply counting acts of violence, highlighting a need for research that could assist the courts to better differentiate between types and severity of violence. Another Australian study of separated couples shows that the majority of both males and females were frightened of their partner before, during, and after separation [12]. There was a distinct difference in the reasons why males and females said they were afraid of their partners' behaviour. Females predominantly spoke about being afraid because of physical/sexual violence, and emotional/ psychological abuse. Approximately half of the women spoke about being afraid because their partners would threaten their life, threaten them with and/or use weapons, and/or threatened they would commit suicide if abandoned. Male victims of violence did not report physical or sexual violence, but reported ongoing harassment and psychological abuse. Some of the men, while very distressed, 'were not fearful of their former partner nor did they report feeling powerless' [12]. Rivera and colleagues [50] argue that psychological abuse is not only more frequently experienced than other forms but can often be more painful and have longer lasting impacts, such as mental health and anxiety issues. --- Family violence and family mediation Ongoing concerns about how the family law courts have dealt with cases involving family violence are well acknowledged [33,51]. This prompted policy changes requiring greater use of counselling, mediation, conciliation, and conferencing as the primary family dispute resolution process, rather than adversarial litigation through the courts [52]. Embodied in this Family Law Act was a list of children's rights, including the child's right to know and be cared for by both of their parents [51]. To facilitate parental cooperation in the ongoing joint care of children post-separation, the Australian Government created a national network of 65 community-based Family Relationship Centres which are intended to be "a first port of call" when families want information about relationship and separation issues [53]. FRCs provide information and referral services to families and free mediation services to separating couples. Attendance at family mediation prior to initiating court proceedings became mandatory for most separating parents who are obliged to make "genuine effort" to resolve their issues. Clients affected by family violence are potentially exempt from Family Dispute Resolution services and FDR practitioners are obliged to screen for the presence of high conflict, coercion and violent behaviour and refer those clients deemed inappropriate directly to court. Implementation of family mediation policies in the context of family violence is nevertheless fraught. Research suggests that family violence is not always recognised by mediation practitioners [51,54], and that even when it is recognised, appropriate actions aimed at creating or preserving safety are not always taken [55]. Furthermore, practitioners express concern about the high percentage of families presenting with disclosed problems of family violence [12]. For instance, 90% of couples attending divorce mediation reported partner violence in one study and only about 7% of cases were actually screened out of mediation [56]. A few studies provide conflicting findings: family violence was adequately screened and monitored in one study [57], and separated couples can achieve comparable levels of agreement, despite different violence histories [58]. However, this is not so true for serious violence. Only 15% of the more violent couples reached full agreement in mediation, compared with overall agreement rate of 55% in another study, suggesting that the most violent couples effectively self -select themselves out of the mediation process [59]. In summary, there have been calls for better research on the processes of separation and divorce in the context of high conflict and family violence [60,61]. This study focuses specifically on couples attending family mediation as a mandatory step in resolving disputes prior to court attendance. It addresses a gap in the research literature by assessing the types and severity of multiple forms of family violence among a high risk sample of couples attending family mediation centres and exploring relationships between types of abuse. We use previously validated scales and additional scales to tap broader definitions of partner abuse. We also examine mediation outcomes and the impact of different types of violence. Such research is important since much of the violence seen within health and human services is understood to fall into the category of intimate terrorism, involving an escalating pattern of coercive control [34]. These are the sort of cases which, under Australian Family Law, should find their way directly into the court system, since they are generally not cases that can or should be assisted by mediation [17]. Yet, there is little research currently that casts light on the type, extent or severity of violence in couples presenting at family mediation, and how that influences mediation or referral to the courts. --- Study aims The primary aim of this study is to examine family violence in the context of parental relationship breakdown and its impact on the family mediation process and post-separation decision making. More specifically, the aims are: --- Methods --- Study design The study used a mixed method longitudinal design to evaluate the impact of family violence on family mediation process and outcomes among clients presenting at nine family mediation centres across metropolitan, outer suburbs, and regional/rural sites in Victoria, Australia. The longitudinal design involved data collection at pretest, post-test on completion of mediation, and a followup post-test six months after completion of mediation. Quantitative data were collected using self-administered surveys at the three time points. Qualitative data were also collected via a telephone interview at the final posttest period. All consenting participants who attended mediation were included in the study. --- Setting The setting for this study was the network of nine family mediation centres or Family Dispute Resolution providers operated by Relationships Australia Victoria . Five sites were located in the Melbourne metropolitan area, one in Melbourne's outer suburbs, and three in regional and rural centres of Victoria. Relationships Australia is an approved family mediation service provider under the Family Law Act 1975. It operates as an incorporated, not-for-profit communitybased secular organisation that has been delivering services in Victoria since 1948. It provides services to the community to build stronger relationships which enhance the lives of individuals, families and communities. As the largest provider of both family mediation and family violence prevention programs within Victoria, and the largest provider of family mediation in Australia, it is in a unique position to support and promote good quality clinical research and strengthens the applicability of our findings. --- Sample Our sampling frame includes all adults referred to the nine family mediation services over a nine month period in 2011. We aimed to recruit at least one individual from each couple. Given high levels of conflict in this sample, we did not consider it feasible to recruit couples as the primary sampling unit. --- Recruitment and procedures When potential participants attended an individual or group information session, the mediator informed them about the study and clients were invited to take an envelope containing relevant information and the premediation questionnaire and pre-paid envelope. If participants chose to be part of the study, they completed the questionnaire and consent form and returned them to the research team. Participants then received a postmediation questionnaire on completion of their mediation. A longer-term post mediation follow up telephone interview was conducted at six months post-test. A monetary incentive to complete the surveys/interview was offered at each stage of the research. Mediators completed a post-mediation survey following completion of the mediation to provide their assessment of the dispute, mediation process and outcome. To facilitate the process of recruitment, a research assistant regularly visited each participating RAV site to collect forms, review recruitment processes and handle any difficulties experienced by agency staff. Mediation staff were contacted regularly to record when participants' files were closed so that they could be contacted for the post mediation follow up. This process commenced in March 2011 and continued for approximately 9 months until a suitable sample size of 121 participants was achieved. Participants who decided not to proceed with mediation or decided to drop out before the completion of mediation were still invited to complete the post and post-post mediation questionnaire which would give the study a quasi-control group to compare with those who proceeded and completed their mediation sessions. The project was approved by La Trobe Human Research Ethics Committee and RAV's Research and Ethics Committee. --- Measures Pre-mediation and post mediation self-report questionnaires were mailed out to participants. The 6 month post mediation follow-up involved a telephone interview and a mailed self-report questionnaire. Table 1 provides a summary of the research aims, methods of addressing these and potential benefits. --- Pre-mediation questionnaire The pre-mediation questionnaire contained a total of 101 questions divided into four sets of items: sociodemographics, mental health, relationship, and conflict variables. In the post-mediation and post-post mediation questionnaires most demographic questions were omitted and additional items about their experience of the service and outcomes were included. Socio-demographics This section contained 9 items that asked participants for their demographic information and nature of their relationship with the person they are mediating with. These latter questions asked about: whether they were still living together; number of years they have been in a relationship; if separated, for how long; and the number of children from this relationship. Participants also indicated their relationship status . Psychological distress Level of psychological distress over the previous four weeks was assessed using the Kessler 6, a widely used screening scale and treatment outcome measure [62,63]. The six questions ask about depressive and anxiety symptoms, such as feeling hopeless or nervous, in the last 4 week period. Participants rated how often they experienced the symptoms on a five point scale ranging from 'all of the time' to 'none of the time' , high score indicating good psychological health. --- Relationship conflict The nature of the parental relationship post separation was assessed using a 5 item scale developed from Emery's Acrimony Scale [64]. The Acrimony Scale is a 25-item measure of co-parenting conflict between separated or divorced parents that yields a single acrimony score, the mean of all items, with higher scores indicating greater conflict and more co-parenting difficulties. The 5 items were selected by an in-house factor analysis of AS scores from a large sample of 800 mediation clients which found that over 95% of variance was accounted for by these 5 items. The 5 items referred to hostility, anger and whether these feelings were expressed in front of the children. Items were rated on a 5 point scale, 1 = almost never, 4 = almost always, and 5 = not applicable to your situation. --- Parental alliance The strength of the parenting alliance between the couple was assessed using the 20 item Parental Alliance Inventory developed by Abidin and Brunner [21]. Parenting alliance is a central variable Knowledge about the parties experience of the mediation and their feedback about the process and outcomes can better inform clinicians about their needs 5. To determine durability of mediated agreements, eg, parenting agreements at 6 month follow-up The qualitative survey at post-post mediation assessed the strength of the parenting agreement The study examines how parents fared up to 6 months after mediation, to assess whether mediated agreements lasted, or whether alternative plans developed. It also examines predictors of durable and successful agreements and impact on parenting roles influencing parenting behaviour and has been related to children's adjustment. Abidin and Brunner [21] reported a Cronbach's alpha of .97 for the PAI, and established moderate concurrent and construct validity by correlating the scale with measures of marital satisfaction, parenting stress and parenting style. All items were reworded to refer to children in the plural, where Abidin and Brunner [21] used wording that referred to 'child' in the singular. The scale asked participants to rate on a 5 point Likert scale how strongly they agreed with statements such as "my children's other parent and I are a good team" and "I believe my children's other parent to be a good parent". Lower scores indicating a greater parenting alliance, with '1 = strongly agree' and '5 = strongly disagree'. Conflict The presence, nature and severity of family violence was measured by four scales. Conflict Tactics Scales Revised [32] was used to measure the extent to which partners engage in psychological and physical attacks on each other as well as their use of reasoning or negotiation to deal with conflicts. The earlier version CTS [42,65] has been the most widely used measure of intimate partner violence, with known validity and reliability [66]. The updated CTS2 [32] provides a better operationalization of the distinction between minor and severe acts and is useful in that it asks the client to report on his or her own behaviour in addition to their ex partner's behaviour. Although the CTS has received criticism for being insufficiently sensitive to circumstances and context [40], it is widely used and across different samples [44,67]. Concurrent validity [68] and construct validity have also been well established, with the CTS correlating with many different measures of etiology and impact of partner violence (for review, see work by Straus and Mickey [67]. It is often employed as a test of concurrent validity when similar measures are developed [69]. The CTS2 scale included 32 items from four subscales: Negotiation , Psychological Aggression , Physical Assault , and Injury . Participants were asked to rate on an 8 point Likert scale how often they and their former partner enacted the behaviours in the past year, with a range of '0 = this never happens' to "7 = this happens more than 20 times in the past year'. The scale and its subscales have been found to have reliable internal consistency, with alpha's ranging between acceptable to excellent [32,44,67,70,71]. It has also been found to have good test-retest reliability in a sample of court-mandated men in a batterer intervention program [44]. The sexual violence subscale was omitted due to sensitivity of the topic in a family mediation context, low internal consistencies [71], and low test-retest reliability [44]. There has been some debate about the factor structure of the CTS2, and the number of factors varies between 3, 4 and 5 factor models, depending on which scales are included or excluded from analyses [32,[70][71][72]. As the scale has been validated in its original factor structure, the present study chose to use Straus' original subscales with the exception of the sexual coercion scale, thus conceptualising the CTS2 as a 4-factor structure of negotiation, psychological aggression, physical assault, and injury. --- Controlling and intimidating behaviour In order to tap the areas of emotional abuse and controlling behaviour that are not directly addressed by the CTS2, a scale was developed to measure controlling and intimidating behaviour. The items were modified from previous measures which had examined emotional abuse [66] and controlling behaviours [43]. The seven item scale tapped behaviours that are controlling and jealous in nature, such as 'one partner kept the other from seeing friends' and 'one partner falsely accused the other partner of having an affair'. As with the CTS2, participants are asked how often they and their partner had enacted this behaviour on an 8 point scale which ranged from '0 = this never happens' to "7 = this happens more than 20 times in the past year'. The scale had good reliability with a Cronbach's alpha of 0.82. Financial abuse A four-item scale was developed to measure financial or economic abuse since this is recognised as an important aspect of dominance/isolation behavior by limiting a partner's access to money [31]. The created scale included a modified item from the Controlling Behaviour Index [43]: reworded as 'My partner deliberately kept me short of money'. The other three items were developed by the research group to measure financial domination described as a way to limit a partner's access to money and other resources in order to produce compliance or conformity [37]. The items asked participants to rate how often they and their partner excluded the other from financial decisions, kept financial situations secret, and controlled the money in the relationship. The four items were measured with an 8 point Likert scale, which ranged from '0 = this never happens' to "7 = this happens more than 20 times in the past year'. This scale also had good reliability with an alpha of 0.85. --- Screen for family violence The 16-item Family Dispute Resolution checklist was used routinely by RAV staff to screen for violence and to assess participants' capacity to mediate without fear and intimidation from their expartner, and was thus included in this study. Participants rated how much they agreed with each statement on a five point Likert scale, ranging from '1 = strongly agree' to '5 = strongly disagree' , higher score indicating greater risk. Some examples of the items include "my partner was aggressive and dominating in our relationship", "I feel dominated/intimidated by my former partner" and "I was afraid of my partner". --- Post-mediation questionnaire The post-test mailout survey contained 85 questions. The Kessler Health scale, AS and PAI were re-administered to assess any changes to the FDR process and outcomes. The remaining questions measured various aspects of the mediation process and outcome as well as assessing the participants' experience of and satisfaction with the sessions. --- Mediation processes Six items asked about the focus of mediation, such as property or parenting issues, and about the outcomes. In addition, satisfaction with the information/intake session and the mediation was scored on a 5 point Likert scale, with higher scores denoting that the sessions were more helpful. This section also asked about the possible longer term benefits of mediation, even if an agreement was not facilitated. The six questions were modified from a previous evaluation of the Broadmeadows Family Relationships Centre , which looked at client satisfaction and specific outcomes of the mediation [73]. --- Client assessment of mediation Twenty items from 10 scales of the Client Assessment Mediation Services questionnaire [74] were included and participants were asked to score how strongly they agreed with a variety of statements on a 7 point Likert scale, which ranged from 1 = very strongly disagree to 7 = very strongly agree. The items were taken from the following subscales: Effective/Sensitive Mediator partner's point of view' ; Empowerment ; Impartiality seemed quite impartial when it came to resolving differences between me and my partner' ; Focus on Issues ; Impact on Spousal Relationship spouse without outside help' ; Satisfaction with agreements ; Emotional satisfaction ; and Adequacy of Information . --- Children and mediation Six questions asked about client's satisfaction with outcomes relating to children, parenting, and parenting agreements: three items from the CAMS; three from the BFRC questionnaire. Items included statements such as 'The mediators provided useful information about parenting during the mediation session' [73] and "Mediation helped to identify useful ways to arrange our parenting responsibilities" [74], and responses were on a 7 point Likert scale. A further two questions asked parents to rate their satisfaction with discussions and outcomes regarding the children on a 5 point likert scale which ranged from 1 = not at all satisfied, to 5 = very satisfied. Four open ended questions about the parenting agreements were also included enabling participants to offer more detail. Finally, one question asked whether the parenting agreement was still working . The latter seven questions were drawn from Balvin and colleagues [73]. --- Conflict and mediation The final set of 11 questions were modified from the FDR and a were a mixture of closed questions and open-ended questions where participants could provide a more detailed response about their experiences of safety in mediation and the safety of the parenting agreement developed for their child. They included participants' experiences of feeling dominated, intimidated and fearful during mediation; information about the existence of an intervention/apprehended/domestic violence/restraining order, whether there was a breach of the order and if the participant or child had experienced abuse outside the mediation session. Finally, participants were asked about any referrals that mediators may have suggested or provided. --- Mediator questionnaire This measure contained 16 routinely collected questions, modified from CAMS. The mediator was asked whether the case progressed to FDR and the reasons why it did not proceed. Whether cases did or did not proceed, mediators were asked for each case about their perception of the parenting alliance, level of inter-parental conflict, whether family violence was a current or past issue, and type and perpetrator of violence. Mediators were also asked whether there was an intervention order, whether they issued a certificate so that the ex-partners can terminate mediation and can access the Family Court and what effect family violence, if present, had on participation in mediation. Referral information was also requested. Where cases proceeded to FDR, data routinely collected by the mediator was also used: model used in mediation, hours in mediation, level of agreement, ages of the children involved, and their level of confidence regarding the implementation of the agreement developed in mediation, ranging from 1 = not at all confident, to 5 = very confident. Apart from assessment of the success of parenting agreements, this information is routinely recorded by the mediator as part of RAV's administrative processes. --- Post-post mediation questionnaire Three scales from the pre and post questionnaires were re-administered in the 6 month followup mailout questionnaire: Kessler 6 [62], AS [64], and PAI [21]. The phone interview consisted of 63 questions in nine sections to explore 6-month outcomes of mediation, particularly related to parenting arrangements and parental relationship. --- Relationship with former partner Respondents were asked whether they were still separated from their partners, the main reasons for the separation, and whether they had felt intimidated or fearful in the presence of their ex-partner. --- Parenting and children Open-ended questions asked about the pre-separation distribution of childcare, their understanding of "shared parenting", current care arrangements, experiences of post-separation parenting, and whether parenting was easier, harder or the same as pre-separation. --- Parental conflict post separation Respondents were asked about any post separation conflict between ex-partners in terms of triggers, frequency, severity, setting, and impact on children. --- Parenting agreement Participants were asked about the Parenting Agreement, including issues discussed , reasons for failure to resolve, any changes to original agreement, and any difficulties with implementation. Using a 5 point Likert Scale, where 1 = not at all and 5 = strongly agree, respondents were also asked to rate 11 influences on the parenting agreement, both positive and negative, such as, 'Information and guidance from the mediator or family dispute resolution practitioner helped assist with the parenting decisions for our children'. --- Post parenting agreement Respondents were asked how much they agreed with seven statements about their children's perception of the parenting agreement, responding on a 5 point Likert Scale . Participants were also invited to comment further on these items. Four additional open-ended questions included: Issues around safety, whether the mediator had acted on safety concerns if relevant, satisfaction, and flexibility of the arrangements. If no agreement had been reached, the respondent was asked to comment on their experience. --- Mediation Questions asked about the pathway to mediation, time frames, the process of completing an agreement, what they would do differently given their current knowledge, and the value of mediation. --- Use of other services Respondents were asked yes/no questions about whether they had accessed a number of different services . If no service accessed, participants were asked if they thought it would have been useful to do so . --- Family violence Family violence issues were explored within the mediation context. For example, respondents were asked to talk about their experience in mediation and whether the agreement ameliorated the level of violence post separation. In the final section, respondents living with family violence were asked to provide feedback about ways to improve services. Themes will be derived using thematic analysis. --- Mediation service Finally participants were asked for any further comments on mediation. --- Ethics Ethical approval for the study was obtained from the La Trobe University Human Research Ethics Committee and the Relationships Australia Victoria Ethics Committee. --- Data analysis Descriptive analyses will be conducted to map the profile of participants referred to family mediation services, in terms of demographic and relationship characteristics, the types and severity of conflict and abusive behaviour, parenting alliance and wellbeing. Comparisons will be made by gender, and between those who proceed with mediation versus those who do not. Structural equation modelling will be used to explore the relationships between variables. The outcomes of family mediation will be examined using regression models. All statistical analyses will be undertaken using SPSS-19. The qualitative interview questions will be coded using thematic analysis. --- Power analysis For the long-term evaluation, a power analysis was conducted as follows. The estimated client base for the nine participating family mediation sites was approximately 600 new couples per year. We conservatively estimated that at least one member of 30% of couples would consent to participate in the study, and that an estimated 10% of those were likely to be declared ineligible following the initial session, yielding approximately 162 eligible and consenting individuals at baseline. We anticipated a 60% attrition rate by post-mediation follow-up and a further 30% by 6 month follow-up, yielding a final evaluation sample of 68 participants. This is sufficient to predict change across time for key outcomes, with a medium effect size, 80% power and a .05 significance level. --- Discussion The coinciding of legislative reforms and sector concerns regarding the prevalence and impact of non-physical forms of family violence warrants an examination of the family violence profile of FDR clients. If we accept that there is a wide definition of family violence events that require a corresponding range of interventions, then parents capacity to participate in FDR will vary as well [45,75]. This paper examines this aspect of family mediation through measuring the profile of violence being experienced by parties presenting at family mediation services and the consequent impact of this profile on the FDR process, the immediate outcomes of FDR and the subsequent durability and sustainability of these outcomes. Although there has been a number of major studies which as looked at the incidence of family violence in separated couples, they have mainly looked at cases that present at the Family Court or as part of large scale surveys of the general population. The significance of this study lies in mapping of client profiles and their exposure to violence during their relationship, comparing the characteristics of this violence and how it manifested in mediation and what kinds of parenting agreements they were able to establish and how well they endured over time. It also evaluated client satisfaction with the service providers and the outcomes that they mediated. The study will also provide an important contribution to the evidence base in determining better screening measures in FDR. Having a better understanding of participant profiles will allow for more targeted screening processes as well as guiding decisions about when mediation could be success with some types of family violence. Other strengths of the study include the large sample size compared to previous studies of this population and the longitudinal design of the study which offered the opportunity to gather qualitative data which will enable further exploration of participants' experiences and clarification of the major themes emerging from the study outcomes. --- Abbreviations FDR: Family dispute resolution; FRC: Family relationship centre; CTS: Conflict tactics scale; CTS2: Conflict tactics scale 2; AIFS: Australian Institute of Family Studies; DV: Domestic violence; RAV: Relationships Australia Victoria; FDRSPs: Family dispute resolution providers; AS: Acrimony scale; PAI: Parental alliance inventory; BFRC: Broadmeadows family relationship centre; CAMS: Client assessment mediation services; GLAMM: Generalized linear latent and mixed model. --- Competing interests The third author is currently CEO of Relationships Australia Victoria, the setting for the study. Relationships Australia Victoria provided funding as an Australian Research Council Linkage Grant partner in the project. While he was actively involved in the design of study and facilitating access to the setting, there was no inappropriate influence on the design or conduct of the study. There are no other competing interests. Authors' contributions HC had primary oversight of the project and contributed significantly to design and methodology, supervision of staff, and writing of study protocol. MS contributed significantly to design of the study and writing of study protocol. AB contributed to study design and manuscript preparation, facilitated access to relationships services and recruitment processes. All authors read and approved the final manuscript.

Background: Family law reforms in Australia require separated parents in dispute to attempt mandatory family dispute resolution (FDR) in community-based family services before court attendance. However, there are concerns about such services when clients present with a history of high conflict and family violence. This study protocol describes a longitudinal study of couples presenting for family mediation services. The study aims to describe the profile of family mediation clients, including type of family violence, and determine the impact of violence profiles on FDR processes and outcomes, such as the type and durability of shared parenting arrangements and clients' satisfaction with mediated agreements. Methods: A mixed method, naturalistic longitudinal design is used. The sampling frame is clients presenting at nine family mediation centres across metropolitan, outer suburban, and regional/rural sites in Victoria, Australia. Data are collected at pre-test, completion of mediation, and six months later. Self-administered surveys are administered at the three time points, and a telephone interview at the final post-test. The key study variable is family violence. Key outcome measures are changes in the type and level of acrimony and violent behaviours, the relationship between violence and mediated agreements, the durability of agreements over six months, and client satisfaction with mediation. Discussion: Family violence is a major risk to the physical and mental health of women and children. This study will inform debates about the role of family violence and how to manage it in the family mediation context. It will also inform decision-making about mediation practices by better understanding how mediation impacts on parenting agreements, and the implications for children, especially in the context of family violence.

from the general population , we lack reliable information for race and ethinic minority older adults concerning: 1) the overall distribution of well-being evaluations and their relevant social correlates, 2) potential differences in the correlates for different well-being assessments, 3) the impact of social relationships involving peers and friends on SWB, and 4) the role of negative social relationships for SWB. The current study aims to address these gaps by examining the relation of family and friend support and interaction to diverse SWB indicators among older African Americans. Given the limited work specifically on SWB, this review incorporates related research on the relationship between family and friend social support and relationships and mental health status. The literature review begins with an overview of the convoy model of social relations as a theoretical frame for the current analysis. This is followed by a discussion of theory and research on social relationships and their links to well-being and mental health, focusing on the general adult population. The next section reviews research linking social support and social relationships with well-being among African American adults overall, followed by research on African American elderly. The literature review concludes with a section describing the focus of the current study. --- Convoy Model of Social Relations The convoy model of social relations posits that social relations are universally necessary, while acknowledging that the level and types of social relations required varies from one individual to another. These important and meaningful relationships, in total, are referred to as one's convoy of social relations . Convoy members consist of family, friends, co-workers, neighbors, and other persons who are significant sources of social support. Convoys are important because they provide individuals with support, including emotional support, assistance, advice, friendship, and caregiving . Given that extensive research has documented the beneficial link between social support and SWB, support convoys are ideally positioned to have a significant influence on individuals' well-being. The convoy model of social relations assumes that qualitative assessments of one's social relations , along with structural characteristics, such as network size, are critical indicators of the social support network and its functioning. That is, when examining social support networks, it is important to assess both the structural characteristics of the network , as well as the individual's perceptions of the quality of their relationships and the social support provided by convoy members . In fact, Kahn and Antonucci suggest that qualitative evaluations of social support networks are stronger predictors of SWB than structural characteristics of social support networks. Kahn and Antonucci conceptualized convoys as consisting of three sets of concentric circles surrounding the individual. These concentric circles represent varying degrees of subjective closeness of network members to the individual. The inner circle consists of network members who are subjectively closest to the individual and provide the most support to the individual. Relationships in this circle are the most intimate-typically parents, spouses, and children populate the inner circle. The outer circle is comprised of persons who, comparatively speaking, are less subjectively close to the individual, but nonetheless are important in the context of social support. Neighbors and co-workers are likely to be in the outer circle. Finally, the middle circle consists of network members who are intermediate in terms of being subjectively close to the individual; that is, not as close as those in the inner circle but subjectively closer than those in the outer circle. The convoy model of social relations incorporates a life course perspective and recognizes the fluidity of social support networks and changes in the composition of convoys throughout the life course. For example, among middle-aged adults, persons 40 to 59 years of age most frequently list spouses, children, and their mothers as members of the inner circle . Persons in their 60s and older, in contrast, are less likely to list their parents within their inner circle, whom they have likely outlived. These findings highlight how fluid an individual's convoy is throughout the life course, with members of the convoy moving in and out of the three circles as new members are introduced into the convoy and other members depart. Moreover, Antonucci and Akiyama found that older adults' convoys are largely comprised of family members, with family members predominating the inner circle while friends and distant family members are located in the outer circle. The predominance of close family members within the inner circle, who provide the most support, demonstrates the importance of family in the context of social support exchanges. --- Social Relationships, Well-being and Mental Health Research on social relationships and health indicates that positive social ties have beneficial influences on SWB. Several studies indicate that social support and positive social relationships have beneficial impacts on mental and physical health and SWB among older adults. For example, diverse features of social relationships and social support are associated with greater life satisfaction , self-esteem happiness and general well-being . Social support and positive social relationships are also protective against depression; persons receiving high levels of social support from friends and family are less likely to be diagnosed with depression and report fewer depressive symptoms . Additionally, both larger social support networks and greater integration within the support network are associated with lower levels of depression. In regards to affect, social support is also associated with lower levels of negative affect and higher levels of positive affect . Further, higher levels of social support from family and friends are associated with fewer reports of daily hassles and lower levels of psychological distress . A growing body of research also examines the impact of problematic social relations, socalled negative interactions , on SWB. Despite the fact that negative interactions are a recognized feature of social relationships, their influences on SWB have only recently been examined in their own right ). In fact, current research indicates that the deleterious effects of negative interactions on SWB and other mental health outcomes are more potent than the positive impacts of social support ). This is the case for several reasons. Social interactions, particularly those involving close associates, are expected to be positive in nature . Negative social interactions, however, are unexpected occurrences that violate this normative assumption and are associated with several undesirable reactions and outcomes. First, one of the prominent features of negative interactions is that the target individual experiences the exchange itself as being a stresssful event. Customary responses to experiencing stressful events such as alarm, heightened vigilence and emotional reactivity , are frequent sequelae of negative interactions. Negative social interactions also evoke longer term negative affect and depressed mood for those who are the target of these messages , as well as impairments in psychological functioning and coping responses to stressors . Further, because negative interactions involve evaluative information about the individual, they call into question and threaten positive self-appraisals and erode perceptions of the self as being competent, efficacious and having self-worth and self-esteem . Secondly, negative interactions impede effective coping because many of the adaptive strategies typically used when confronted with stressful events are themselves dependent upon notions of personal competency and self-efficacy . Moreover, individuals typically solicit coping assistance and supports from social network members when confronted with problems. However, negative interactions that involve members of one's social networks can complicate the help-seeking process. In effect, negative interactions interfere with and restrict the use of emotional and tangible support resources from others, which is a well-recognized psychosocial mechnism linking social engagement with health and well-being outcomes . In sum, because negative interactions are perceived and reacted to as stressors, adversely impact positive self-conceptions, and interfere with the individual's ability to use cognitive and social resources to effectively manage stressors, they represent a combination of mechanisms and processes that have potential adverse impacts on mental and physical health. In fact, accumulating evidence indicates that negative interactions are associated with adverse mental and physical states , produce high levels of distress for individuals and persist over time . Thus, it is expected that this cascade of adverse effects from negative interactions will be associated with decreased SWB among older African American adults. --- Social Support, Well-being and Mental Health: African Americans Research specifically on African Americans confirms a positive association between social support and mental health and SWB for this group. For example, frequent support from extended family and being subjectively close to family members are associated with greater life satisfaction . Further, subjective family closeness, having fictive kin, number of friends to discuss problems with, and contact with neighbors are positively associated with levels of happiness . Studies specifically focusing on mental health outcomes indicate that social support is negatively associated with depressive symptoms . Similarly, Lincoln and Chae found that frequent emotional support from family is related to a decreased likelihood of a depression diagnosis, and reported satisfaction with received social support is associated with less severe depressive symptoms . Okun and Keith's work on the quality of social interactions found that positive social interactions with family and friends were associated with fewer depressive symptoms. Social support is inversely associated with reported psychological distress , suicidal ideation , and suicide attempts . Finally, emerging research on negative aspects of social relationships reveals that, among African Americans, individuals experiencing higher levels of negative interaction are more likely to report depressive symptoms and have a higher likelihood of being diagnosed with depression . Further, negative interaction with family members is associated with increased psychological distress and suicidality . --- Social Support, Well-being and Mental Health: African American Elderly The few available studies on social support and SWB relationships among older African Americans are consistent with findings for the adult population. Social relationships and support are positively associated with well-being and life satisfaction , while inversely associated with psychological distress . Further, research on suicidal behaviors indicates that the lack of social support and instrumental aid from a confidant is associated with greater risk of suicidal ideation ; having fewer close confidants and limited contact with friends is associated with completed suicide . However, in contrast to these findings, Lincoln et al. found that emotional support from family members was unrelated to having a mood or anxiety disorder and the number of diagnosed psychological disorders. Although overall older adults are less likely to report negative interaction, it, nonetheless, has deleterious effects on their SWB and mental health. High levels of negative interaction with family and friends is associated with a lower sense of mastery and greater psychological distress compared to those experiencing low levels of negative interaction. Negative interaction is positively associated with number of DSM-IV conditions among older African Americans including higher odds of having a lifetime mood disorder, a lifetime anxiety disorder and the overall number of lifetime mood and anxiety disorders . Finally, it is important to take into account whether demographic factors are associated with SWB among older African Americans. Prior work indicates that older age itself is associated with higher levels of life satisfaction, happiness, and SWB among African Americans, both within the entire adult age range, as well as persons 55 years and older . Older African Americans who are married report higher levels of life satisfaction and happiness compared to those who are separated, divorced, or widowed . Finally, income is positively associated with self-esteem and life satisfaction, though its association with life satisfaction is equivocal . In summary, this broad body of work suggests that social support and relationships are associated with positive SWB outcomes, while negative interaction has harmful associations with a range of SWB and mental health indicators. Unfortunately, because relatively few studies focus specifically on older African Americans, these findings await further confirmation within appropriate samples. --- Focus of the Study The present study examines the social correlates of three measures of SWB among older African Americans. The study incoporates several social support and relationship measures that are assessed for both family and friend networks. Based on prior research, we expect that findings will converge with existing evidence regarding their associations with SWB measures . With respect to possible differential impacts of family versus friend factors on SWB assessments, the convoy model suggests that family are prominent members of an individual's support convoy and thus, family factors may be more important than friend factors for SWB assessments. Although tentative, we also anticipate potential differences in the social relationship correlates of specific SWB assessments for several reasons. First, different SWB measures tap distinctive domains of experience. Life satisfaction reflects cognitive or evaluative assessments of life quality, whereas happiness taps affective content and self-esteem is thought to reflect eudemonic content . Further, measures of social network relationships differ with respect to the objective vs. subjective nature of their content. Objective measures of social network relationships provide information on the specific characteristics of networks. In contrast, measures of the qualitative features of social network relationships represent subjective evaluations of these relationships, which tend to demonstrate stronger associations with psychosocial outcomes than do objective measures. In a similar vein, research on social support conveys indicate that qualitative features of convoy relationships demonstrate stronger associations with SWB than do structural characteristics . Given these associations, we anticipate that factors reflecting qualitative aspects of social relations will have stronger associations with SWB evaluations than objective measures . We further anticipate that qualitative aspects of social relations will have stronger associations with happiness and selfesteem ratings as compared to life satisfaction assessments . Finally, prior research indicates that although social support and negative interaction co-occur within social networks, they are conceptually discrete and impact SWB and mental health in distinctive ways . Accordingly, we anticipate that social support will be associated with higher levels of life satisfaction, happiness, and self-esteem, while the opposite will be true for negative interaction. --- Methods --- Sample The National Survey of American Life: Coping with Stress in the 21st Century was collected by the Program for Research on Black Americans at the University of Michigan's Institute for Social Research. The African American sample is the core sample of the NSAL. The core sample consists of 64 primary sampling units . Fifty-six of these primary areas overlap substantially with existing Survey Research Center National Sample primary areas. The remaining eight primary areas were chosen from the South in order for the sample to represent African Americans in the proportion in which they are distributed nationally. The African American sample is a nationally representative sample of households located in the 48 coterminous states with at least one Black adult 18 years or over who did not identify ancestral ties in the Caribbean. The data collection was conducted from February 2001 to June 2003. A total of 6,082 interviews were conducted with persons aged 18 or older, including 3,570 African Americans, 891 non-Hispanic whites, and 1,621 Blacks of Caribbean descent. Fourteen percent of the interviews were completed over the phone and 86% were administered faceto-face in respondents' homes. Respondents were compensated for their time. The sample for this analysis consists of 837 African Americans who are aged 55 or older. The overall response rate was 72.3%. This is excellent given the difficulty and expense to conduct survey fieldwork and data collection among African Americans who are more likely to reside in major urban areas. Final response rates for the NSAL two-phase sample designs were computed using the American Association of Public Opinion Research guidelines for a more detailed discussion of the NSAL sample). The NSAL data collection was approved by the University of Michigan Institutional Review Board. --- Measures Subjective Well-Being-Three SWB variables are examined in this analysis . Life satisfaction is measured by the question: In general, how satisfied are you with your life as a whole these days? Would you say very satisfied , somewhat satisfied , somewhat dissatisfied , or very dissatisfied ? Overall happiness is assessed by the following question: Taking all things together, how would you say things are these days? Would you say you are very happy , pretty happy , or not too happy these days ? A few respondents volunteered that they were "not happy at all" . Self-esteem is measured by the Rosenberg Self-Esteem Scale . The scale is comprised of 10 statements reflecting respondents' self-perceptions, and responses were given based on a 4-point Likert type scale with 1 indicating strongly disagree and 4 indicating strongly agree. Higher values on this scale indicate higher self-esteem levels. Social Support Network Correlates-Several indicators of social support are included as measures of social support network. Subjective closeness to family is assessed by the question: How close do you feel towards your family members? Would you say very close , fairly close , not too close , or not close at all . Frequency of contact with family is measured by the question: How often do you see, write or talk on the telephone with family or relatives who do not live with you? Would you say nearly everyday , at least once a week , a few times a month , at least once a month , a few times a year , hardly ever , or never . Subjective closeness to friends and frequency of contact with friends are measured by questions similar to the family network variables. Negative interaction with family members was evaluated with a three-item index. Respondents were asked, "Other than your how often do your family members: make too many demands on you, criticize you and the things you do, and try to take advantage of you?" The response categories for these questions are very often, fairly often, not too often, and never. Although negative interactions, subjective closeness, and frequency of contact all assess varied characteristics of social relations, negative interactions specifically underscore the adverse elements of social relations. Accordingly, higher values on this index indicate more frequent negative interactions with family members. Several demographic factors are included as covariates. Missing data for family income and education were imputed using an iterative regression-based multiple imputation approach incorporating information about age, sex, region, race, employment status, marital status, home ownership, and nativity of household residents. Income is coded in dollars, and for the multivariate analysis only. Natural log transformation was used in order to address the skewedness of income . The natural log of income was also used in order to increase effect sizes and provide a better understanding of the net impact of income on the SWB variables. --- Analysis Strategy All analyses are conducted using Stata 11.2, which uses the Taylor expansion approximation technique for calculating the complex design-based estimates of variance. All of the analyses utilize analytic weights. Statistical analyses account for the complex multistage clustered design of the NSAL sample, unequal probabilities of selection, nonresponse, and poststratification to calculate weighted, nationally representative population estimates and standard errors. Based on prior research, regression models are estimated for all SWB variables in relation to their social support correlates. Similarly, prior research suggests that family factors may interact with one another in their effects on SWB. Interaction terms are constructed and tested in regression models for the SWB variables. All analyses control for demographic differences. --- Results The demographic characteristics of the sample and the distribution of the study varaibles are presented in Table 1. Approximately 60% of the sample is female, and the mean age of respondents is 66.7 years. Mean family income is $27,652 and, on average, respondents report some high school education . More than half of respondents reside in the South and close to one-third of the sample is widowed. In general, respondents report high levels of life satisfaction, happiness, and self-esteem. With respect to social support and network characteristics, respondents indicate relatively frequent contact with family, feeling subjectively close to family and relatively minimal levels of negative interaction with family. Respondents also report relatively high levels of subjective closeness to and interaction with friends. Results of the regression analysis for life satisfaction are presented in Table 2. Subjective closeness to family is positively associated with life satisfaction. In contrast, negative interaction with family, family contact, and friend contact and friend closeness are all unrelated to life satisfaction . In Model 2, frequency of contact with family is positively associated with life satisfaction; the significant interaction between family closeness and family contact on life satisfaction indicates that contact with family has a greater effect among older adults who are not subjectively close to their family than those who are close to their family. For those who are subjectively closer to their family, increased contact only marginally increases life satisfaction ratings. However, for those who exhibit low levels of closeness to family, increases in family contact are associated with a substantial increase in life satisfaction. Turning to happiness ratings, subjective closeness to friends, closeness to family, and negative interaction are associated with happiness . Specifically, older adults reporting higher levels of subjective closeness to friends and subjective closeness to family are also more likely to report higher levels of happiness, while those reporting high levels of negative interaction with family have lower happiness ratings. Contact with family and contact with friends, however, are unrelated to happiness evaluations. The significant interaction between subjective closeness to friends and negative interaction with family indicates that respondents who are close to their friends and experience minimal negative interaction with their family report the highest level of happiness. Further, it appears that negative interaction levels with family have less influence on happiness for persons who are subjectively close to their friends. Older adults who are not close to their friends and also experience high levels of negative interaction with family have very low levels of happiness. As shown in Table 4, subjective closeness to friends and negative interaction with family are associated with self-esteem. Older African Americans reporting higher levels of closeness to friends exhibit higher self-esteem than those who are less close to their friends. Additionally, individuals who experience greater negative interaction with family report lower self-esteem than those who experience minimal negative interaction. Family contact, friend contact and closeness to family are unrelated to self-esteem. --- Discussion This investigation of the impact of social support and social relationships on older African Americans' SWB makes several unique contributions to a small but emerging body of research . This analysis, based on a national probablity sample of older African Americans, investigated both family and friendship relationships and their positive and negative associations with several indicators of SWB. Overall, our study finds that both family members and friends make unique contributions to the well-being of older African Americans and relationships with family members both enhance and diminish well-being. However, these effects were not universal across all of the SWB measures examined. Subjective closeness to family was related to higher levels of life satisfaction and happiness, but not self-esteem, while closeness to friends was associated with higher levels of happiness and self-esteem, but not life satisfaction. Frequency of contact with family was predictive of higher levels of life satisfaction . These findings indicate that social relationships involving family and friends are important for assessments of SWB among older African Americans. As anticipated, we found that measures of subjective closeness to family and friends were more important than contact with family and friends for SWB, particularly as positive correlates of happiness and self-esteem. However, an anticipated positive relationship between family closeness and self-esteem was not verified. Further, while we expected family closeness to be less important for life satisfaction , it was associated with life satisfaction in the form of a statistical interaction with family contact. Overall, these findings are consistent with other work indicating that family and friend relationships are important for older African Americans in terms of emotional support and companionship, as well as other forms of assistance . Family members tend to be reliable and stable sources of social support for older adults and become especially important for older African Americans who come to rely more heavily on kin due to declines in their peer social networks as they age .. However, prior research also indicates that friendships are important for the well-being of older adults. Social support from friends is associated with elevated levels of self-esteem and well-being and lower levels of depression and loneliness . Friendship network size is positively associated with happiness , and more frequent contact with friends is correlated with greater levels of SWB . In fact, in certain contexts, friendships can exert greater influence on individuals' SWB than family relationships ; friendships are often of higher quality than family relationships because older adults can more easily disengage from unsatisfactory friendships than is the case for negative family relationships . The positive influence of subjective closeness with friends found in this study underscores the importance of qualitative features of friendship for self-evaluative or eudemonic and affective components of SWB evaluations; this was not the case for life satisfaction assessments. Negative interaction with family was associated with lower levels of happiness and selfesteem, but was unrelated to life satisfaction. These findings are consistent with research suggesting that negative interactions are associated with negative affect , undermine positive self-perceptions and hinder effective coping behaviors and psychological functioning . Prior studies on African Americans also found that negative interaction is associated with a lower sense of mastery , greater psychological distress , and greater odds of being diagnosed with a range of mood and anxiety disorders . The frequency-salience theory indicates that although negative interactions are less likely to occur than positive social exchanges, their impact on SWB is clearly substantial. In fact, negative interactions are often perceived as stressors due to their unexpected nature , the fact that they deviate from general expectations of civility, and because they are experienced as upsetting and stressful events. For these reasons, negative interactions adversely influence SWB, particulary affective dimensions of SWB. In the present analysis, the absence of a relationship between negative interaction with family and life satisfaction supports the notion that life satisfaction evaluations constitute cognitive or evaluative assessments of life quality. In contrast, happiness and self-esteem draw more heavily on affective content and personal perceptions of self, respectively, which are more vulnerable to the impact of negative interactions with family. Interestingly, contact with friends was not a significant correlate for any of the SWB measures indicating that it is not a reliable correlate for older African Americans. Instead, subjective appraisals of relationships had stronger associations than structural features of social support networks . This is consistent with expectations from the convoy model of social relations, in which relationship quality exerts greater effects on SWB than the structural characteristics of social support networks . The interpretation of the significant interaction between subjective closeness to family and contact with family for life satisfaction further supports the notion that subjective appraisals are more pivotal as correlates of subjective SWB than are structural features of networks for particular groups of older persons. Irrespective of their reported level of contact with family, older adults reporting high levels of subjective closeness to family, also had high levels of life satisfaction. Apparently, older adults' positive appraisals of their familial relationships compensated for the infrequent contact they had with their family. Thus, despite infrequent family contact, persons with higher levels of subjective family closeness experienced high levels of life satisfaction. In contrast, persons reporting low family closeness and low family contact had the lowest levels of life satisfaction; however, increases in contact with family was associated with higher levels of life satisfaction. The fact that family closeness was strongly associated with SWB confirms notions from the convoy model about the importance of qualititative aspects of relations and emphasizes the critical influence of family relationships for SWB. Furthermore, the fact that frequency of contact with family members had no effect on life satisfaction for respondents who indicated high subjective closeness to family members supports the socioemotional selectivity theory . The socioemotional selectivity theory suggests that older adults are at a developmental stage in which they perceive their remaining time in life to be limited. Because of this perspective, older adults tend to reorient their goals to focus more on emotionally meaningful aspects of life, including relationships, and maximizing positive emotional experiences. As a result, subjective closeness to family members, which taps into emotional meaning, may be especially important for life satisfaction in older adults. It may, in fact, override the negative impact of infrequent family contact on life satisfaction. That is, even when older adults have infrequent contact with their family, if they are subjectively close to their family they still exhibit high levels of life satisfaction because they derive emotional meaning from this closeness. The interaction between subjective closeness to friends and negative interaction with family on happiness ratings indicated that closeness to friends offsets the impact of negative family interaction on happiness. In contrast, older adults who were not close to their friends and experienced high levels of negative interaction with family reported the lowest level of happiness. In essence, the detrimental impact of negative interaction with family on happiness was diminished for older adults who where subjectively closer to their friends as compared to those who did not feel close to their friends. This finding confirms the deleterious effects of negative interaction on SWB evaluations, as well as the beneficial impact of positive friend relationships in offsetting negative family interactions. Although the average negative interaction score for the sample is relatively low, the significant main effects of negative interaction on happiness and self-esteem, coupled with the interaction effect between negative interaction and subjective closeness to friends, demonstrates the potency of negative interactions on SWB. These findings are consistent with research indicating both direct and indirect relationships effects of social support on SWB . The direct positive effects of family closeness for happiness and friend closeness for self-esteem, are consistent with a large body of research on social support linkages to decreased feelings of loneliness and sadness and increased feelings of trust . Further, within stress and coping frameworks social support is important in buffering the impact of stress, such that when a person is faced with a stressful situation, they evaluate and mobilize the psychological and social resources available for coping with the stressor and respond accordingly . Our findings similarly indicated that social support from friends is a critical social resource that mitigates the negative effects of negative family interaction on happiness. This confirms findings from previous studies indicating that support from friends buffers the negative effects of partner strain on psychological well-being . In the presence of marital conflict, supportive friendships also buffers against lowered levels of marital sastisfaction . Additionally, support from friends has been shown to mitigate the harmful effects of friendship conflict on physical health . Friends serve many roles for older adults, ranging from companions and condidants to caregivers, In fact, support reciprocity, which is associated with relationship satisfaction, tends to be higher in friendships than in relationships with adult children . Further, friends provide a range of support including companionship, instrumental support , and emotional support . For certain types of support, such as companionship and coping with bereavement issues, friends are more preferred than family . Friendships can influence psychological well-being in several ways. First, friendships are perceived as achieved relationships, whereas familial relationships are perceived as ascribed relationships . Consequently, friendships can provide a sense of accomplishment and competence in interpersonal relationship domains. Second, prior research has demonstrated a strong association between friendship quality and psychological well-being . For example, Antonucci, Lansford, and Akiyama found that older women who had close, intimate friends in whom they could confide reported lower levels of depressive symptoms than women who did not did not have confidants. Although previous research among African Americans has largely focused on relationships with family, the current analysis revealed the importance of examining both family and friendship correlates of SWB among older African Americans. The use of several relationship measures involving both family and friends, provided a more complete representation and understanding of the functioing of older African Americans' family and friend networks. In addition, multiple measures of SWB permitted a more in-depth examination of their distinctiveness in how family and friend support and social interaction factors are associated with dimensions of SWB. Overall, the findings demonstrated the importance of family and friend relationships in bolstering SWB and the detrimental impacts of negative family interaction on selected aspects of SWB. Further, the findings identified situations embodying specific risks for lower SWB for older African Americans; that is, limited family contact coupled with low family closeness for life satisfaction and low friendship closeness in the presence of high negative family interaction for happiness. Despite the strengths of the present study, interpretations of these findings should be examined within the context of the study's limitations. All measures in this study were selfreported, which is susceptible to recall and social desirability biases. Because segments of the population such as homeless and institutionalized individuals were not represented, our findings are not generalizable to these subgroups. Additionally, although findings supported the deleterious influence of negative interactions with family members on SWB, we were unable to investigate the impact of negative interaction with friends on SWB, as the NSAL did not have this information. Future research should examine the relation between negative interactions with friends, in addition to negative interaction with family members, and SWB to determine if negative interactions impact SWB differentially depending on the source of the interaction . Lastly, causal inferences concerning the connections between support and social interaction and SWB are problematic with crosssectional data and longitudinal data are preferred. Nevertheless, this study provides a more comprehensive picture of the associations between family and friend support and interaction and SWB that verified that family and friendship networks can be both benefical as well as detrimental to SWB. Our analysis further found that qualitative features of support networks were generally more important for SWB than structural features of networks . Study findings contribute to a growing literature on SWB and the role of both positive and negative relationships on SWB within diverse segments of the older population. More broadly, this study reinforces the importance of focused research on race/ethnic minority groups within the United States in advancing a more nuanced understanding of the social correlates of SWB within these groups. Interaction between friend closeness and negative interaction on happiness. --- --- ---

Gerontological research confirms that subjective well-being (SWB) (i.e., life satisfaction, happiness) is an important indicator of the psychological status of older adults. SWB evaluations represent overall assessments of quality of life that encompass both positive and negative features (Diener et al. 1984;Diener 2000). Although there is a large body of research in this area, few studies focus on elderly racial and ethnic minorities and research on older African Americans is especially limited. Further, several questions regarding assessments of SWB and their social correlates are unresolved. First, because SWB is multidimensional (Jivraj et al., 2014), different aspects of SWB are thought to be conceptually distinct in terms of whether they reflect cognitive or evaluative (i.e., life satisfaction), affective (i.e., happiness), or eudemonic or self-assessment (i.e., self-esteem) dimensions. In addition, these components of may have different social correlates (Jivraj et al., 2014). We currently have little information as to whether family and friendship support and relationships have distinctive impacts on various well-being constructs (i.e., life satisfaction, happiness, self-esteem). Second, well-being studies examining the impact of family networks and social support typically assess only positive features of these relationships. Less is known about how social connections with peers and friends and problematic social relationships (e.g., conflict, criticism) are associated with diverse measures of SWB. Third, because most well-being studies of older adults focus on samples

Introduction The academic study of the relationship between unemployment and offending amongst young people is supported by both a feast and a famine of literature. There is an apparently limitless self-renewing supply of panel and cohort studies that map the patterns of statistical association between these two phenomena, at a great range of levels of aggregation, and other variables across many countries. The economists, psychologists and others who pursue these analyses invariably identify a positive statistical relationship between unemployment and offending amongst young people, often over extended periods. For all the abundance of data they draw upon, these analyses offer no clear indications of direct causality in the links between unemployment and offending. In contrast, a very small number of researchers using predominantly qualitative methods intermittently tackle this vexed relationship. Some achieve only glancing analytical engagements with the elusive links . A very few others, in the form of local studies using relatively small samples, aim to understand the relationship between unemployment and offending in terms of context, meanings, causes and the choices made by young people but are limited by the difficulty of transferring and applying context-specific evidence and interpretations elsewhere. This paper provides a new analysis of the connections between young people's unemployment and offending in exceptional recessionary times, based on recent data and interventions. In doing so, it charts the apparent dissipation of the dominant positive pattern of connection between the two in the contemporary UK, and considers whether the present pattern can be explained by recent risk-based policies. In the absence of clear evidence that this is so, the paper explores other interpretations of an apparently changing interface between unemployment and crime, setting them in the context of major cross-national increases in youth unemployment, and the serious concerns of some major Inter-governmental Organisations about its impact on social cohesion. The paper concludes with some reflections on the 'responsibilities and rights' discourse at a time of major demand failure in youth labour markets. --- The fragmenting association of youth unemployment and crime The 'economic causes of crime' thesis anticipates that the archetypal linkage between a weak economy, rising youth unemployment and increased offending should never be more evident in the UK than at present. Remarkably, however, the current profile appears to be almost the inverse. At no time since the 1930s have economic recession and unemployment impacted so greatly on young people in the UK. As Figure One shows, the sharp and sudden upturn in youth unemployment rates at the onset of the 2008/9 recession reversed a long-declining trend. Unemployment amongst young people reached its highest rate since records began, climbing to 1.2 million in 2011. Four of every ten 16 to 17-year-olds were classified as not economically active . Almost one in five 16 -24-year-olds were economically inactive. [Figure 1 --- [Figure 3 here] On the face of it, the worst recession in modern times has resulted in a marked decline in offending. And while attempts to demonstrate historically consistent indices of association between unemployment and crime have foundered , this inversion is not only unprecedented and counterintuitive, it is a potential threat to the paradigm upon which 15 years of risk-based practise in youth justice has been founded -an observation to which we return later. Analysts now face the perverse proposition that recessionary conditions appear to suppress the incidence of offending. --- Unemployment and crime: a brief history The historical relationship between unemployment and crime rates for all ages is complex and contested. Analyses using regression modelling to produce precise quantifications of the shifting pattern have a long, disputatious and fraught history in the literature . Meta-studies have sought to weigh competing claims. Tarling's overview identified a majority of studies that found no evidence of a relationship between offending and unemployment. Box observed that 32 of 50 studies found a significant relationship between the two. Knepper argues that most analysts agree that crime rates reflect unemployment rates over the long term, but that these vary by type of crime. Bell and Blanchflower's review identifies numerous studies that find significant relationships between crime and unemployment. These two more recent meta-studies therefore suggest one way forward. --- Differentiating types of crime Differentiating types of crime may help explain why some crime rates sometimes rise in times of high unemployment. Bell and Blanchflower report that 'as unemployment rates increase, crime rates tend to rise, especially property crime' . Wu and Wu's study used estimates based on UK regional data for the effects on crime rates of variability in earnings inequality and unemployment between 2002 and 2007. They find that 'crimes motivated by economic gain are highly correlated with income inequality and unemployment' and that 'there is a clear distinction between economic and non-economic crimes' . But taking into account different types of crime, the most recent analyses in the USA suggest that the patchy match between rising unemployment and rising crime continues, with strong evidence that since the onset of recession violent crime and property crime fell by about 5%, while robberies -often most associated with recession -fell by 10% in a year from 2009. . While some of the most recent data for England and Wales reflects these counter-typical trends, as Figure Four shows, the total aggregated flat-lining CSEW data masks some contrary data for crimes that are claimed to be those that are most causally associated with unemployment and financial duress. The incidence of opportunistic crimes like 'other household theft' along with thefts of personal property rose markedly soon after 2009, and the long-standing continuous decline in burglary and vehicle-related theft ceased in the same year. --- [Figure 4 here] It is clear that descriptive statistics alone show that differentiating types of crime moderates claims that the current trend breaks prevailing historical patterns of association between unemployment and offending. --- Who and what counts? In addition to differentiating types of crime, further refinements need to be considered. Firstly, one of the effects of welfare reform and the shift to conditionalised unemployment benefits has been to alter significantly the respective proportions of working age people who are registered as unemployed and who are assigned to welfare-to-work programmes. It is not only changes in the unemployment rate that might correspond to increases in property crime: more stringent benefit regimes may also have a more pronounced effect. Machin and Marie analysed these effects and concluded that 'the benefit cuts and sanctions embodied in the stricter JSA regime shifted people off the benefit system and raised crime '. . Confining analyses to crime rates thus gives only a partial picture. Secondly, there are fundamental methodological difficulties with studies which estimate the links between unemployment and crime using panel data. Aggregate data gathered for one purpose are placed alongside aggregate data gathered for another to examine the relationship between shifts in the rates of both over time. The data used show the incidences of both measures in particular periods at aggregate levels, not multiple identifiable individual cases ; Wu and Wu, op.cit.). Overall, aggregate studies do nothing to show that unemployed people are more likely to offend, or that offenders are more likely to be unemployed. If the purpose of analysis is to understand causation and test economic causes of crime theories, isolating a wide range of influences on changing crime rates is essential. Levitt's renowned studies suggested that the strong US economy over a decade of sustained growth in the 1990s played little or no role in the decline in rates of offending, compared to other more specific variables during that period, notably increases in police numbers, prisoner numbers, and the control of crack-cocaine alongside the legalisation of abortion. Most correlational studies lack this breadth of scope and depth of contextual analysis, and are thereby considerably limited in the deductions that they can safely make. On the basis of the research and evidence reviewed here, it is possible neither to dismiss a significant connection between economic conditions/unemployment rates and crime, nor to demonstrate a secure relationship, nor to assert demonstrable causal connections. --- Youth Crime and Unemployment Age differences can be expected to exert a significant influence on the unemployment-crime relation, because of the wide range of conditions under which young people experience unemployment. Specific studies of this relationship amongst young people aged 16 -24 are, however, remarkably scarce, and with the exception of those noted above, are almost exclusively concentrated on large-cohort aggregated data sets over time. Dickinson , however, reports an small scale qualitative study of 399 18-year-olds dating from 1971-2. Those who were unemployed were about three times as likely to offend. Property crime was more common. Dickinson also argues that young men in recessionary times are more likely than other groups to commit crimes when they are unemployed. It is nonetheless difficult to find clear data that demonstrates this. Carmichael and Ward's large scale aggregate data study in England and Wales found that youth unemployment is positively related to burglary, robbery and criminal damage rates, but observes 'whether it is the unemployed themselves that are committing the crime is another question' . The sole large-scale study of young people that makes any claims of a direct causal connection and concludes that ' youth unemployment has a positive and robust causal effect on most property crimes' . --- The statistical bifurcation of youth as an age category These three analyses strike a notable consensus on the strong positive correlation between acquisitive crime and unemployment amongst young people. But each takes a different view of the nature of the relationship identified. Dickinson A more direct indicator is the number of young people sentenced -although this too is restricted to reported crimes. It is remarkable that, as Figure Five shows, a steady state in numbers sentenced began a series of sharp progressive falls coinciding with onset of the recessionfrom 78,000 in 2008/9 to 71,000 in 2010/11. This provides unequivocal evidence of a sharp decline in the number of offences coinciding with recession. [Figure 5 here] However, the disaggregated data shows some significant distinctions. Between 2007/8 and 2010/11 all categories of proven offences showed reductions, but these reductions were sharply differentiated. Figure Six shows that the greatest reductions over this period were in motoring offences , criminal damage and breach of a statutory order . The reductions in some forms of acquisitive crime were markedly less: robbery and burglary . Amongst acquisitive crimes, only theft and handling stolen goods had declined more sharply . --- [Figure 6 HERE] Overall, then, the data is ambiguous. Amongst adults aged 18+ there are some indications that despite a marked continued fall in the number of offences, acquisitive crime rose during or after the recession, whilst a similar overall trend in reduced recorded offences amongst 10-17 year olds shows only some slow-down in the rate of comparable offences for some acquisitive crimes. The significance of this data is further complicated because it is based on two different methodologies. The adult data is based on CSEW reportage which is prone to errors of sampling and respondent recall, but has the benefit of recording a high proportion of unreported crimes. The data on young people captures only proven offences. The former source is equally likely to overestimate or underestimate the actual number of offences, for a variety of reasons ; the latter is certain to underestimate actually occurring offences. --- The statistical invisibility of offending amongst 18-24 year olds Rates of offending amongst 10 to 17-year-olds have continued to decline less sharply than first appeared, alongside increasing levels of youth unemployment. One explanation is that the age of peak offending has been delayed. YJB data shows that Youth Offending Team caseloads increase very markedly with age: YOTs work with more than twice as many 17 year olds as 14 year olds . The peak age of offending is usually estimated at around 18 years , continuing the progressive rise in age-related rates from 14 to 17 years. Although Figure Seven shows that 17 is the age of peak offending, the rate of decline in offending by age cohort above that age is relatively slow up to the age of 20, and the 21-24 age group still offends more than older groups. --- [Figure 7 here] A number of plausible interpretations of the emergence of the mooted delay in the age of peak offending make this an important line of enquiry. One would suggest that YJB tactics of preventative intervention have succeeded in containing, controlling or diverting offending within the 10 to 17-year-old age range. As a result, young people who desist or who avoid reoffending may experience the transition to the adult criminal justice system at 18+ as a relaxation of the regime and so offend more than 17-year-olds. A second interpretation similarly emphasises a number of intensive interventionist measures to minimise the numbers of 16-18 year olds who can be classified as unemployed through extended compulsory schooling and other forms of post-16 participation. While such measures fall far short of protecting this age-group from the depredations of worklessness they serve both to delegitimise claims of ill-effects, and to place considerable pressures on families and households to absorb such effects. A third interpretation is that the sequential removal of entitlement to benefits and allowances for almost all 16 to 18-year-olds between 1988 and 1996 has imbued a sense of the inevitable dependency of this interstitial age-group in the minds of young people and their parents alike. This serves to normalise 'self-selected' economic inactivity in ways that ameliorate resentment about the lack of jobs and other opportunities. Difficult as it is to demonstrate the presence and reach of such responses, some recent studies of the intra-familial effects of recession point to similar adaptations . None of the published data allows this line of enquiry to be pursued. Published CSEW and PRC data does not routinely differentiate 18-59 year olds by age. In effect, this means that the highest profile age-specific impacts of economic effects on offending rates amongst 18-24 year olds are concealed within the data for the 18-59 age group. This major omission has particular significance for understanding offences by young people. In-depth independent research has shown shifting patterns of particular offence types that vary significantly by age. Soothill's study of the 1953 birth cohort in England and Wales shows that more robberies, burglaries and thefts are committed by 16-20 year olds than by any of six age categories across the 16-40 years span. Indeed this agegroup is by far the most prolific in all three categories of offending. The absence of more recent corroborative analyses obscures important insights into the variable links between offending and unemployment. This has considerably more significant implications. There is clear evidence that the 18-24 age group experiences the first, the most extreme and the most long-lasting effects of recessions upon the conditions of labour markets. The cessation of recruitment of young people by employers as the first, easiest and least costly economy measure manifests itself in extreme rates of unemployment in their age group. This nearuniversal phenomenon often results in youth unemployment rates at least double the adult rate. In the UK the peak count of 1.2 million unemployed 18-24 year olds is widely believed to substantially underestimate actual youth unemployment rates. In all, efforts to test the relationship between recession and offending amongst young people are hamstrung by lack of differentiated data. These observations might be taken to imply that the persistence of acquisitive crimes amongst under 18-year-olds shown in Figure Six is continued or exaggerated in contiguous age cohorts. This would also reflect the observed recent increases in adult personal theft and 'other household theft' noted above. Exceptional data derived from police records by the YJB shows an increase in the total number of people sentenced for indictable offences since the onset of the 2009 recession. However, consistent with the other data, the steady progressive reduction in the numbers of under-18-year-olds sentenced since 2007/8 is reflected here. But it is also notable that a marginal reduction in offending amongst 18-20 year-olds began at the same time. Although the age ranges covered in Figures Eight and Nine are not an exact match, the divergence of ascending unemployment rates alongside declining rates of offending is reinforced by two sets of data which straddle the 17/18 age divide. Thus, over the same ten-year period, these tables respectively show the steady decline in rates of offending at the same time as rates of unemployment and other nonparticipation begin their ascent. In terms of absolute numbers, the totals of young people 'not in employment, education or training' show a relatively regular trajectory of increase from 2001 to 2011. However, this occurs in the context of a demographic decrease in the size of these age cohorts over this period such that, proportionally, the numbers of young people who are NEET remains fairly steady for the first eight years of the decade, and then begins its exceptional rise in the third quarter of 2009. [Figure 8 here] [Figure 9 here] The current decline in offending in times of high unemployment apparently once again further undermines the 'economic causes of crime' thesis. On the other side of the argument the persistence of acquisitive crimes within an underlying downward trend of offending suggest that the thesis may remain defensible if sufficient differentiated data were available -most notably immediately above the 18+ cut-off line. --- The Youth Justice Board and reduced offending: cause and effect? One change in the conditions under which the apparent inversion of the relationship between unemployment and offending has occurred is that it followed the establishment of the YJB, albeit several years later. The intensive, highly regulated modes of preventive intervention based on risk assessments managed through YOTs might well account for the decline in youth offending. Not only did YJB strategies reach maturity at the time of a decline in the numbers of recorded offences from 2008/9 onwards: one key factor in the risk profiling calculus which guides intervention is non-participation in employment, education and training. This approach targets the very young people whose lack of economically or educationally gainful activity may have led them to offend, and provides a plausible basis for inferring a causal connection between YJB practices and reduced offending. The YJB's own self-assessment does not make any claim for credit for the change. Its assigned performance measures are benchmarked to reductions in first-time entrants to the criminal justice system, reoffending, and the use of custody. YJB was able to demonstrate reductions in all three . However, none of these criteria have any necessary connection with an overall reduction in rates of offending. All could in principle be the product of selective targeting and priorities alongside an overall increase in offending. Notably, the YJB itself makes no claims to have reduced offending ] Certainly, there are many evaluations of the work of the YJB that would lend support to claims of its broad effectiveness and that of YOTs ). Others have been considerably less confident of the association between interventions and reductions in crime . At this point it is important to recall two caveats. Firstly, overall rates of offending across the adult age range have also continued to decline since 2008, in part of the criminal justice system over which YJB has no jurisdiction. The supposedly counterdominant trend for the number of offences to fall as unemployment rises can therefore reasonably be assumed to have other causes which are independent of the YJB's distinctive interventions. Secondly, for 10-17 year olds the only official data is derived from police crime records, which are acknowledged by the Home Office to undercount the total number of crimes committed. The CSEW's record of selfreported crime by victims offsets this limitation, and as a result gives a considerably higher estimate of the overall incidence of crime. But its data cannot differentiate offences committed by 10-17 year olds from those of adults. The crime count for young people must therefore be assumed to underestimate the incidence of actual offences. It is clear that attempts to associate YJB practices with reduced offending in any direct causal way lack a sufficiently clear empirical foundation, and that data on the incidence of offences committed is an underestimate. It is not safe to attribute a perceived decline in youth offending to the work of the YJB. --- Re-calibrating the calculus of risk: the paradox of success Attributing reductions in offending to the YJB also leads towards an uncomfortable paradox. Unemployment and non-participation are prominent risk factors in the YJB's risk assessment methodology. What, then, would be their significance in circumstances in which risk-based preventive interventions had succeed in breaking the claimed connection between unemployment and the offending to which it gave rise? If aggregate levels of association between unemployment and offending had been demonstrably weakened by the YJB's practices, what would be the rationale for retaining unemployment as a factor in the case-specific calculus of risk of offending? Revised models would surely have been needed that demoted or excluded unemployment as a risk factor. If the current pattern of weakened association is sustained and the data concerning types of crime and over-18s are resolved, it is clear that, whatever the causes of the change, the models too should change. This apparent 'paradox of success' whereby targeted interventions might have helped render redundant the very risk calculus that guided their targeting suggests that risk assessments are as inherently limited in their capacities to adapt to the exigencies of volatile economic conditions as are other analyses of connections between unemployment and offending -whether causal or spurious. Put differently, the uncertainties highlighted in the foregoing analysis would surely no longer provide a credible basis for including unemployment as a factor in risk profiling. Its connection to offending in current times is at best highly tenuous, and at worst a way of legitimising the intrusive management of vulnerable and disadvantaged categories and classes of young people. At this juncture it is salutary to recall that aggregate patterns of statistical association between unemployment and offending are insufficiently strong to support claims of causal connections; but that the claimed association may nevertheless be defensible if sufficient offence-specific and age-differentiated data were available. The uncomfortable tension between these two statements makes for a less-thancompelling case to persist with a faltering if not flawed mode of analysis. This constitutes something of a 'parting of the ways'. The arguments rehearsed here come to a head in a stark and difficult choice: to refine and extend the calculus of risk and its associated policies and practice, or to find alternative explanations for and responses to the apparently shifting relationship between unemployment and offending in times of major socio-economic change. --- Social cohesion and the delayed effects of unemployment One prospectively crucial alternative explanation counsels caution in assuming that the unemployment-crime nexus has changed significantly. Just as unemployment is a well-established 'lagging indicator' of economic recession, so also some of the most adverse manifestations of the effects of unemployment show a relatively systematic delay. There is an extensive literature on a range of so-called 'scarring' effects of unemployment on young people too large to cite here in detail. While it is not consensual, some significant tendencies are evident. For econometricians, periods of unemployment in youth have quite reliably strong adverse long-term effects on earning power . Socialpsychological studies reliably demonstrate reduced self-esteem, self-confidence and sociality . Other contextual and individual psychological variables associate unemployment with depression and suicidal tendencies . More broadly-based sociological studies tend to associate unemployment with manifestations of social exclusion and alienation. Many of the relevant effects are indeterminate, discernible only through attitudes, dispositions, degrees of withdrawal and so-called 'disengagement' that make claims of delayed effects difficult to substantiate. Suicide and attempted suicide are among the few finite junctures against which delayed effects can be measured. And here, there is some general agreement that, in young men in particular, this extreme outcome is mostly likely to occur between one and two years after the onset of unemployment . --- The international rise of social unrest Far more important than the delay interval is the clear evidence that, at the level of the individual, it takes time for the damage of inactivity and exclusion from labour markets and other modes of productive activity to be realised. It would therefore be unremarkable if the time-lag between the individualised experience of being unemployed and a public and/or collectivised expression of frustration or anger at this condition was commensurately longer. The evidence from the Mediterranean countries that experienced major youth protests in 2011 and subsequently supports this hypothesis. In most of North Africa and in Greece and Spain extraordinarily high In some instances, the responses constitute significant shifts in position. Until 2010, the International Monetary Fund , had been silent on youth unemployment. Remarkably, its first intervention on the subject focussed concluded that […] 'the labour market experience of today's youth will have deep adverse impacts on the faith in public institutions of future generations. . This is a surprising departure for an IGO concerned with economic not social stability. Even more striking is the shift of position at the Organisation for Economic Cooperation and Development . Until the global financial crises and the sharp rise in youth unemployment, the OECD's position had been heavily invested in its predominant strongly neo-liberal stance and its assertively anti-welfarist position . By 2011, its main annual employment report commented: Investing in youth and giving them a better start in the world of work should be a key policy objective. Otherwise, there is a high risk of persistence or growth in the hard-core group of youth who are left behind, facing poor employment and earnings prospects. In a context of ageing populations, OECD economies and societies simply cannot afford the large economic and social costs that such an outcome would entail. Awareness of the social implications is particularly significant here, sufficient to prompt the OECD Directorate to urge member nations to target intensive assistance, to make temporary extensions to the safety net as 'vital to prevent poverty', and to provide income support, and effective, reliable social protection . The International Labour Organisation's attention to social unrest and its implicit connections with crime take the debate a significant step further. One report envisages an explicit causal link: Unemployment breeds social exclusion that, in turn, gives rise to high welfare dependence, crime and anti-social behaviour… The depth and breadth of the current youth employment crisis, and the social unrest that is unfolding, underscore how much is at stake in international and national efforts to avert a second and potentially more dangerous phase of the global crisis… These powerful statements are founded in substantial research undertaken by the ILO's Institute for International Labour Studies. Its annual report shows that social unrest is increasing worldwide especially in the advanced economies. Globally, unemployment is the largest and most significant determinant of risk of unrest . Other studies support an historical association between poor job prospects amongst young, educated people and public protests , and between austerity measures and social protests . Recent evidence from southern Europe and North Africa powerfully supports this thesis A number of recent speeches by the Director General of the ILO have underscored this connection. At the Davos Summit he drew on unreferenced data that had counted more than a thousand cities across 82 countries that had experienced youth protests during 2011 . Subsequently, he applauded what he described as ' a powerful reassertion of activism from young people who refuse to accept a future of unemployment, marginal work and expensive, poor quality education' ; and supported this by stating his belief that 'there is a growing conviction of the need to change course stimulated by social movements and protests in many countries, themselves fuelled by the growth of inequality and intolerable levels of youth unemployment' . In the same year the ILO's crisis report on youth unemployment, Time for Action, concluded: The situation of youth employment thus deserves urgent attention. Not only does it threaten to violate the principle of equality and solidarity between generations, which is an important aspect of social justice, but any further prolonging or deepening of the crisis will also increase the likelihood of political and social unrest as more and more young people lose faith in the current economic paradigm. This is a stark warning of the potential consequences of inaction. In case the ILO's words be thought alarmist and exaggerated, many commentators would agree that faltering faith in the current economic paradigm motivated many during the uprisings of the Arab spring, in which the key role of young people and the prominence of unemployment and an endemic absence of economic opportunities have been identified as important ingredients 2012). The increase in some key indicators of social unrest has been as great in the 'advanced economies'. The responses of young people in Greece and Spain offer an alarming insight into the ways in which weakening confidence in an economic paradigm begin to manifest themselves as the beginnings of classic crises of legitimacy. In a prescient speech to the prestigious Brookings Institution two years earlier the ILO Director-General was warning that: The crisis has again put before our eyes something that we all know: good jobs, quality jobs, decent work are, everywhere, central to the lives of women and men. Decent work is a source of personal dignity. Stability of family and households. Peace in the community. Trust in government and business and overall credibility of the institutions that govern our societies. --- Unemployment, crime and social cohesion Importantly, what connects these commentaries from leading IGOs is an emerging focus on threats to political legitimacy and social cohesion posed by the exclusion of young people from labour markets and wider social and economic participation. Indeed, the most thorough, evidenced recent analysis of social cohesion in this context that is available comes from the World Bank. It dedicated a significant strand of its World Development Report 2013 to the subject . The chapter on jobs and social cohesion states: …cross country analysis of values surveys finds that job loss or lack of access to jobs is associated with lower levels of trust and civic engagement. …In extreme cases, if people, particularly youth, lack jobs and hope for the future, they may turn to violent or criminal activity to compensate for the absence of self-esteem and sense of belonging that a job might otherwise provide. The text is concerned with the correlates of unemployment and a range of attributes and dispositions of people who are unemployed, focussing on social trust, community and political particiapiton. But the explicit conception of social cohesion is grounded in social-psychological categories and individual behaviours. As such it lacks a fully social -or economic -conception of cohesion that takes into account structural factors. By comparison, Green et al's comprehensive study is commendable. It is a major comparative modelling project across [n] countries using a typology of 'regimes of social cohesion' acknowledged to be heavily derived from the work of Esping-Andersen . For all the limitations of this approach, it provides some well-analysed indicators. One of the assigned indices of social cohesion is the level of state management of labour markets and employment protection alongside levels of income inequality. Unremarkably, this marker finds the Social Democratic Nordic countries and to a lesser extent the Social Market countries of most of the rest of Europe to have high levels of institutionally embedded state-driven social cohesion. Characterised as a Liberal regime, in contrast, Great Britain exhibits lower levels of social cohesion on this indicator: less employment protection and greater income inequality, but also compensatingly higher levels of civic participation, also taken to be indicative of a more socially cohesive societies. More significantly for this discussion, across the board, greater extremes of income inequality are found to be closely associated with higher levels of violent crime, and taken together these are presented as significant markers of weak social cohesion. This is the profile that characterises Great, in greatest contrast to Social Democratic regimes where incomes are considerably less unequal and violent crime rates significantly lower. Positivist high-volume, high-aggregation studies like those of Green et al and the World Bank are open to the same methodological criticisms that applied to risk analyses and studies based on inferential statistical association considered earlier in this paper. And many other definitions, indices and interpretations of social cohesion are available. Nevertheless, their sheer international scale, the robust strengths of the associations they report, and their contextualising differentiation of regime types carry some weight. Many of their findings are echoed in different ways in more nuanced, qualitative analyses that associate exclusion from labour markets with tendencies towards lower levels of social and economic integration of a kind that evidence the 'scarring' effects of unemployment The sharp distinctions which Green et al's study identifies between Great Britain's model of social cohesion, and that of most of the rest of Europe inevitably prompts speculation about the different ways in which young people have responded to mass unemployment across all three social cohesion regime types. In the Social Democratic Nordic countries, street protest by young people about unemployment has been minimal and overall crime rates remain low. In the Social Market countries of Mediterranean Europe where public protests have been most frequent and voluble, overall violent crime rates are amongst the lowest in Europe, but income inequality is much greater than in the Social Democratic countries. And in Great Britain, violent crime is the second highest of all the countries analysed, far in excess of other European countries, but income inequality is broadly the same as that for the Mediterranean Social Market regimes. These observations make a strong prima facie case that the youth crime and unemployment link is weakest in the Nordic Social Democratic countries, and strongest in Liberal Great Britain. In the Nordic countries this profile is associated with minimal protest, in the Mediterranean countries with recurrent and mostly peaceful protest that directly articulates objections to the economic injustices of unemployment and inequality; in England with a single explosive episode of violent rioting in August 2011 involving extensive criminal damage, which was not directly articulated with a specified unified set of injustices. It would be rash to draw conclusions from these observations without thorough assessment of the age-specific incidence of crime, inequality and unemployment in these countries, and without a comprehensive review of the forms of protest and other mass reactions. But even from this brief overview it is clear that the concept of social cohesion should be axial to any analysis that purports to explain increased levels of crime or mass protest in relation to endemic unemployment. But the insights which a full analysis could be expected to bring forward are capable of providing an entirely different interpretation of the inversion of the historical patterns of association between unemployment and offending. On this reading, social protest is a manifestation of delayed effects of extended unemployment which, as some IGOs have begun to infer, result from weakening social bonds and diluted social solidarity. Whether protest is an alternative to crime -and thus in some contexts might explain the weakening link between unemployment and offending -or whether it takes criminal forms that re-configure that link is far from clear. Either way, delayed protest or delayed offending as responses to being unemployed may mean that the full effects of mass youth unemployment have yet to manifest themselves. Once again, this line of interpretation leads to a prospective methodological 'parting of the ways'. One response is to persist with the apparently fast-diminishing returns from aetiologically-inspired cohort studies that aim to 'see inside' the points of between social justice and criminal justice of a kind that has special significance for responding to norm infraction amongst young people. Of fundamental relevance to a system of youth justice that is located within its social and economic policy context For that overwhelming majority of young people who have nothing to sell but their labour, the failure of the basic universal chartered rights to employment, to the free choice of employment, to freedom from economic exploitation, and to just and favourable remuneration between the ages of 16 and 24 is clear. --- Responsibilities, rights and 'mutual obligations' It is highly significant that one of the most penetrating discourses of recent times straddles the fields of welfare / unemployment policies, and criminal justice policies. New Labour's insistence that rights carry responsibilities has a distinctively multivalent capacity to cross these policy fields. Young people in particular are enjoined to take responsibility for their own actions or accept the consequences of not doing so. In the context of labour markets, this entails accepting participation in work programmes in lieu of contracts of employment when no work is available. In welfare and social protection policy, it entails readiness to work. And in youth criminal justice policy it entails meeting conditions of conduct, participation in behaviour management and other programmes, and observing restrictions on movement and association in lieu of custodial or other sentences. It is thus against the responsibility to meet prescribed norms of participation and conduct that rights to employment or to social protection are to be honoured. This 'mutual obligations' discourse has always implied a balance between the inputs through which responsibilities are discharged, and the outputs each individual claims 'by rights'. Its credibility depends on the commensurate nature of inputs and outputs. It was achieved in the highly conducive conditions of the longest boom of the postwar era. It made the underlying bargain of maintaining tolerable minimum living standards in exchange for actual jobs or simulated work sustainable . This publically-sanctioned 'mutual obligations' approach was one of the transformative features of New Labour's consolidatory normalisation of neoliberal market economics and neoliberal social governance . Their faltering and contested introduction under previous Conservative governments gave way to the infinitely more effective managerialised and governmentalised structures and processes of New Labour's centralist forms of governing see for example . As the thresholds of young people's increasingly conditionalised entitlement to unemployment benefit, housing benefits, supplementary benefits and other now-defunct means of financial support were raised, young people's tolerance for the 'rights/responsibilities' bargain was maintained by generally buoyant youth labour markets. The conditions of this bargain begun to falter with the onset of the 2008/9 recession. With the election of the coalition government in 2010, the political-economic context shifted much more significantly. The removal of the safety valve of buoyant labour markets began to throw into much sharper relief incommensurate rights 'outputs' in return for responsible 'inputs' -and the eroded mutuality that this implies. The absence of sufficient employment opportunities are the essence of the emerging disjuncture. In addition, unreasonable pressures upon young people to accept places on programmes which provide no skills or development, to work without pay and to accept levels of weekly remuneration that could not sustain independent living for a day grossly exaggerate reasonable expectations of responsible participation. An emergent discourse of 'disengagement' attributes failure to compete in labour markets to unwillingness to gain qualifications and accumulate skills in circumstances in which it is beyond question that the failure to gain employment is the result of demand failure in a large majority of local labour markets. Such conditions so powerfully exaggerate individual responsibility for worklessness as to risk destruction-testing the credibility of the mutual obligations discourse. The palpable erosion of the rights to work, to free choice of employment and to just and favourable conditions and remuneration now threatens the legitimacy of the "rights and responsibilities" discourse. This, it is crucial to remember, is the discourse which became the axis of settlement which disabled and mollified protest and resistance in the 20-year transition from Social Democratic to Neoliberal market and welfare conditions in the UK. --- Concluding comments Across the piece, quantitative analysis has demonstrated weak predictive and explanatory powers and a poor capacity to account for atypical trends in rates of unemployment and the incidence of offending amongst young people in the UK. Despite this, the same correlational, inferential and actuarial statistical techniques as have been used in such studies continue to provide the core models for the methods of risk profiling which have shaped the dominant approach of youth justice practice in England and Wales for the past 15 years. Some puzzling paradoxical and potentially contradictory issues arise. As we have noted, it is unclear why techniques that have had such a limited success in identifying a significant relationship between unemployment and offending are deemed adequate contributors to the processes of risk profiling which determine who will be the object of intensive surveillance and intervention in the current practices of youth justice. Rather than revise the parameters for the correction and refinement of techniques that have, at best, been only partially successful, other explanations for the countertypical divergent trend of unemployment and offending can lay strong claim to being afforded new levels of priority for research and policy alike. One approach briefly outlined here is to consider the evidence that the unique characteristics of the present recessions may have the effect of delaying responses on the part of young people. In the absence of clear and reliable evidence, events beyond the UK have highlighted the very real possibilities that responses to unemployment can take quite different forms. Modes of social unrest and manifestations of extreme discontent abroad already have partial parallels with the English Riots of 2010. Once again, the reflex response of research and policy analysis leans towards the proto-aetiological, focusing on efforts to profile the characteristics and circumstances of rioters and establish parameters of causality . However, the surprisingly congruent responses of four powerful IGOs have drawn attention to the threats to social cohesion posed by extremes of extended or endemic levels of youth unemployment -in one case to issue stern warnings of the risks of radicalisation and loss of confidence in the dominant economic paradigm. By raising serious questions about the continued credibility of the 'mutual obligations' and 'rights and responsibilities' approaches as imbalances intensify between what is provided for and what is demanded of young people in increasingly adverse conditions, this paper has emphasised the priorities and principles that underpin fundamental human rights that should surely frame all systems of youth justice. Translating such rights into workable practicable youth justice policies deserves serious consideration of a kind that it has not received for many decades. There has been a resurgence of rights-based initiatives -for example the Decent Work Initiative and the Global Social Protection Floor spearheaded by UN agencies. These merit careful exploration and costing on premises that have considerably higher aspirations than the minimalistic, disciplinary and exploitative modes of job creation and diversion from labour markets that currently characterise provision for young people without work. An essential part of such calculations would be more thoroughgoing research into the crime reduction effects of such measures than have currently been available. The benefits to social cohesion, to remaking a flawed economic paradigm and to the reassertion of chartered human rights are potentially great indeed. Some substantial diversion of research and policy endeavour away from modelling and aetiological approaches that have poor and unproven returns, and towards lines of enquiry that include an appropriate recognition of the human and social as well as economic costs of unrest and weakening social cohesion has rarely been more warranted in modern times. --- articulation between unemployment and offending -or make better calculations of the determinants of weakening social cohesion. Alternatively, this may be a critical moment at which to consider some of the fundamental principles of social and economic organisation that underpin social cohesion. Here, the words of the ILO report quoted earlier, that the principle of equality and solidarity between generations is an important aspect of social justice, seem particularly pertinent to an analysis that is cognisant of the centrality of social cohesion to this debate. --- Responsibilities and the principle of the right to work In the multiple layers of policy revision and re-steering of the youth justice system in England and Wales over more than six decades, it is easy to lose sight of the principles which should inform every system of youth justice, especially if it is also committed to securing social justice. Goldson and Muncie outline a 'critical anatomy' of such principles. They take the International Human Rights Framework as providing the founding precepts for any such system , to argue that: Ethically legitimate, rights-compliant and effective approaches to youth crime and justice must be located within a broad corpus of social and economic policy rather than the narrower confines of youth/criminal justice policy . There could be no better illustration of the importance and relevance of this assertion than the preceding discussion. The current socio-economic context fundamentally conditions the operating circumstances of the youth justice system of the UK. --- Understanding this policy context is essential for ensuring an appropriate alignment

This paper explores competing accounts of an apparent inversion of the previouslyprevailing relationship between young people's unemployment and the incidence of youth offending at a time of economic recession. It begins by highlighting the faltering association between unemployment and offending, and considers the paradoxical implications for risk-based methodologies in youth justice practice. The paper then assesses explanations for the changing relationship that suggest that youth justice policies have successfully broken the unemployment-offending link; and alternatively that delayed effects of recession have yet to materialise, by reference to the work of four Inter-governmental organisations and to youth protests outside the UK. In place of ever more intensive risk analyses, the paper focusses on the adverse effects of unemployment on social cohesion, and proposes a rights-based approach to youth justice that recognises the growing disjuncture between the rights afforded to young people and the responsibilities expected of them.

Introduction Humans need education as the basis for lives. Through education, humans can develop their full potential so that human are able to solve problems that arise in the lives. Education can make humans to socialize, communicate and interact well one another. Thus, humans raise their standard of living both economically and socially. Education is not only able to raise human glory to the other humans but also to Allah SWT. Education includes the interaction of educators and students to achieve the vision of education such formal and non-formal educational institutions. The purpose of education is to provide guidance so that students can live independently to continue and preserve traditions such as values that develop in society. Through well-managed and intensive education programmed, the optimum point for educational endeavors will be realized. Education is successful if it can change human behavior in a positive direction 1 . Learning is an obligation for every Muslim. Allah will exalt the degree of those who believe and those who are given knowledge according to His word Q.S. Mujadillah verse 11 which means: "O you who have believed, when you are told, "Space yourselves" in assemblies, then make space; Allah will make space for you. And when you are told, "Arise," then arise; Allah will raise those who have believed among you and those who were given knowledge, by degrees. And Allah is Acquainted with what you do" In addition, the Prophet also ordered to deepen the religious knowledge "Whoever Allah wills to be given goodness, that person deepens the religion of Islam" 2 . It shows that studying in Islam is a process without end or what is known as long life education which is in line with the principles set by Allah SWT and His Messenger. Demanding knowledge is not only done by children but also parents. Parents who are preoccupied to work certainly cannot get the knowledge that expect from formal educational institutions. Therefore, the age and time factors are not possible, they will also rethink the financial factors that parent have, most of them will choose to meet the daily needs. To deal those problems parents will look for other alternative ways to be able to gain knowledge and deepen religious knowledge. Parents can not only get education through formal education, but also can get it through non-formal education. One of the non-formal educations that still exists today is Majelis Taklim. The Majelis Taklim is not only for parents but is also open to the public, including youth who wish to gain knowledge through this non-formal education Islam is a religion that guides humans individually and in groups to become good, moral, and virtuous human beings. To achieve religious goals, a dynamic called da'wah is needed. Da'wah is an appeal or teaching that is carried out by a preacher to Mad'u either through oral, written or deed to do what Allah SWT commands and stay away from His prohibitions. The presence of da'wah as a coaching, educational and directing activity has given new prospect to educate and enlighten society efforts, especially in the religious and social. One of the da'wah program or educational institutions around the community is the Majelis Taklim. Therefore, the Majelis Taklim does not only function as a da'wah forum, but also plays a role to develop and foster Islamic and religious knowledge in the community. The main purpose of forming Majelis Taklim is to spread Islamic da'wah and save the people from adversity, therefore Majelis Taklim have grown rapidly in Indonesia, which are attended by teenagers and parents. The beginning of the formation of this Majelis Taklim was an attempt by Muslims to spread Islamic da'wah through mosques, but nowadays da'wah is hold not only in mosques but also hold many places, not even only verbally but through social media such as Youtube, Facebook, Whatshap and others. Based on the history, the Majelis Taklim is the oldest educational institution in Islam because it has been implemented since the time of the Prophet Muhammad SAW which took place clandestinely in the house of Arqam Ibn Abu al-Arqam.3 However, preaching in secret ways did not last long after Allah's command to carry out preaching openly contained in Q.S. Al-Hijr verse 94 means: --- "Therefore, expound openly what thou art commanded, and turn away from those who join false gods with Allah." There are many Majelis Taklim during society in Indonesia where most of the population is Muslim. One of the taklim assemblies that is growing rapidly is at the Al-Hidayah Majelis Taklim, Curup Village, North Curup District. Majelis Taklim, which is in RT 07/RW 03, Dusun Curup sub-district, Curup Utara District, is followed by dozens of congregations every routine Friday afternoon Taklim Assembly. The study in this taklim assembly is a study of tahsin and tahfidz. based on the importance of increasing religious understanding for everyone, a person's desire to join the taklim assembly that is around his environment will arise. Based on the description above, further research is needed regarding the role of the Majelis Taklim in increasing religious understanding. The purpose of this study is to describe the role of the alhidayah Majelis Taklim in increasing religious understanding4 . The contribution of this research is to develop the treasures of knowledge, especially about religion and provide benefits for religious taklim assemblies so that they are more consistent in practicing religious teachings. The method used in this study is a qualitative approach. According to Sugiyono, a qualitative research method is a research method used to examine natural object conditions, where the researcher is the key instrument. Data analysis is a step for systematically searching and compiling data obtained from interviews, observations, and documentation by organizing data into categories, choosing which ones are important and will be studied so that they are easily understood by oneself or others 5 . The analysis in this study uses the Miles and Huberman model such as data reduction , data display . --- Results and Discussion --- The role of the Majelis Taklim Al-Hidayah to improve religious understanding The Majelis Taklim as a non-formal educational institution has a very big role for the congregation. In religious matters, the Majelis Taklim makes a very large contribution to society, because the main purpose of the Majelis Taklim is to prohibit religious knowledge. Therefore, the existence of this Majelis Taklim is very helpful to the community in meeting their spiritual needs. The existence in the life of the community, the Majelis Taklim has a role in which its existence is needed by the community. Majelis Taklim is a forum for the community to always get knowledge, especially knowledge about Islam. So that the Majelis Taklim means always optimizing its functional role in society. The Majelis Taklim every Friday which is held in the Dusun Curup sub-district gets a good response from the congregation, as evidenced by the enthusiasm of the people who take part in the Majelis Taklim, the increasing number of congregations and the large number of people who donate to this Islamic boarding school. Seeing the enthusiasm and positive response from the congregation, the Majelis Taklim every Friday always tries to optimize its role and existence to coach the ummah to increase religious understanding for its congregation6 . Majlis taklim is a community-based educational institution characterized by Islamic values which in its implementation has the principles of education with an open system and a lifelong process. Through the Majlis taklim hoped that the community can learn religious knowledge, so that from the results of the educational process it is expected to be able to make a contribution that is quite influential in the formation of a superior Islamic generation, a generation that is faithful and pious, has noble character, fosters a sakinah family so that it can support and realize the nation's hopes towards a state that fair and prosperous. The existence of Majlis Taklim in society has brought benefits to the people, especially those who are members. As parents, they should need knowledge to educate their children, but many of them have low education, lack of knowledge and insight caused by minimal economic conditions, which hinders them from obtaining the knowledge they need. Furthermore, Majlis taklim come to make a big contribution and give beneficial to society. By participating of Majelis Taklim, the majority of whom are parents, will be able to add insight both in terms of religious knowledge and other general knowledge. The roles or contributions of the Majlis taklim Al-Hidayah Council of the Dusun Curup sub-district are: --- a. Faith Development The role of the Majelis Taklim which has been quite dominant so far has been in fostering the soul and spiritual mentality of the congregation, so that many of them become more obedient in worship, have strong faith, and are active in preaching. It caused by Majelis Taklim which are always related to issues of religion, faith, and piety which is carried out intensively, routinely, and continuously, and attended by all congregations and the Majelis Taklim administrators. The congregation of the Majelis Taklim Al-Hidayah Council of the Curup also get the benefits such fostering and spiritual soul so that, it can develop the faith of the member. Majelis Taklim plays a role to fostering the faith of the congregation by explanations given by the speaker of the congregation every Friday, it can increase the religious understanding of the congregation. The Majelis Taklim also has an impact on the spirituality of its congregation so that the psychology of the Majelis Taklim every Friday, add peace of mind to the congregation, increase the faith of the congregation. The cases are same to the aim of the Curup Majelis Taklim al-hidayah such as guide people to carry out worship that accordance to Islamic religious teachings contained in the Al-Qur'an and As-Sunnah. It can view that Majelis Taklim every Friday has a real impact on its congregation. The role needs to be maintained properly in the activities carried out by Majelis Taklim, moreover Majelis Taklim is one of the pillars of da'wah in society which has a strategic position to fortifying the people's faith from various influences that can undermine their faith. This will be more suitable to this era because challenges and disturbances of faith are increasingly, besides of that there is also an increase in polytheism, disobedience in people's lives in the world which can no longer be controlled. Base on the explanation the Majelis Taklim has a very strategic role because of its direct presence in the community. Furthermore, the Majelis Taklim has great potential and strength to overcoming various challenges and obstacles to the faith of the people so that the activities carried out by Majelis Taklim can truly fortify the faith and strengthen. By sticking to the Qur'an and Sunnah, life will be directed. As we know that, one of the functions of the Qur'an is to guide human life. By being guided by the Al-Qur'an, every people will be able to lead a more directed life. However, on the reality people cannot understand the Qur'an because the content is too global, so it requires more deeper understanding to understand the contents of the Qur'an. Based on the problem about, an interpretation study is needed. One of Majelis Taklim that uses interpretation as their study material is at the Majelis Taklim Al-Hidayah. The main material presented at the Majelis Taklim is the study of tahsin and the practice of worship, and a question-and-answer session. As an effort to increase religious understanding for the members of the Majelis Taklim al-Hidayah Dusun Curup, this material is presented as innovation to help the congregation to be able to understand contents of the Qur'an. It is hoped that after participating in the Majelis Taklim Al-Hidayah Dusun Curup, the community will increasingly understand the Al-Qur'an, so that they can adhere to the Islamic teachings contained in the Al-Qur'an. By increased understanding of the contents of the Qur'an, it is hoped that the faith of the members of the Majelis Taklim will also increase in the routine recitation activities every Friday afternoon. --- b. Education of Sakinah in theFamily Become a Sakinah in the family is the what the married couple and family hoped, moreover a sakinah in the family is a process and goal of a marriage in Islam, Allah SWT said in Q.S. Ar-Rum verse 21 which means that: "And one of His signs is that He created for you spouses from among yourselves so that you may find comfort in them. And He has placed between you compassion and mercy. Surely in this are signs for people who reflect." 7 The Sakinah in the family is not only reflected to the scope of internal social relations among family members in a household but also reflected in his association of neighbors, relatives, and the whole family, both far and near family. Thus, education is very necessary in fostering a Sakinah in the family. Majelis Taklim Al-Hidayah Dusun Curup can play a big to solve problems and difficulties in family life, especially those faced by the congregation of Majelis Taklim members in social life and in forming and building a sakinah, mawadah and warohmah family. 8 Based on the explanation above, the Majelis Taklim is held every Friday as routine recitation activities and questions and answers about religion. This question-and-answer activity give an opportunity for the congregation to ask questions about what material they do not understand. Many members ask problems in family life because most of the worshipers were those who were already married. Majelis Taklim contributes through recitation activities to help to solve daily problems so that it is hoped that it can become a vehicle for family education to become a Sakinah of the family. By recitation activity or question and answer activity, congregations who do not understand or for congregations who have problems about religion, or the family also could learn more deeply. --- c. Empowerment of the Dhuafa Islam teach people to have concern for the fate each other, especially for this poor people, as what Allah SWT said in Q.S. Al-Baqarah verse 83 which means: "And ˹remember˺ when We took a covenant from the children of Israel ˹stating˺, "Worship none but Allah; be kind to parents, relatives, orphans and the needy; speak kindly to people; establish prayer; and pay alms-tax." But you ˹Israelites˺ turned away-except for a few of you-and were indifferent." 9 It supposed that Muslims who are able to help those who are less/not able to ease the burden of the lives of the poor in meeting their daily needs. The activities that can be carried out by the Majelis Taklim such as Sponsorship, care, and education for orphans. Compensation and social assistance to the poor and displaced people. Provision of food and medical assistance to people experiencing disaster. Collecting zakat, infaq, and alms that are benefit of the poor. The function of the Majelis Taklim is not only as a place to gain religious knowledge but also as a place to carry out social activities for the community. As is done by the Majelis Taklim every Friday. In this Majelis Taklim also carry out social activities, one of which is sponsorship activities for orphans in the month of Muharram. The month of Muharram is a noble month, a special month. The month of Muharram is also commonly referred to as the orphans' Eid which is used as a moment to share with orphans. The month of Muharram has many virtues as contained in Q.S. An-Nisa verse 36 means that: "Worship Allah ˹alone˺ and associate none with Him. And be kind to parents, relatives, orphans, the poor, near and distant neighbours, close friends, ˹needy˺ travellers, and those ˹bondspeople˺ in your possession. Surely Allah does not like whoever is arrogant, boastful-." 10Based on the verse above contains instructions that Allah forbids people being arrogant and proud of what peole have because everything that is deposit from Allah. To avoid this arrogant attitude, God commands to do good to others, especially to orphans and to the poor. Based on explanation above, the Majelis Taklim every Friday has a big role for the poor in providing social assistance and improving the economy of the poor themselves. As for the activities carried out by the Majelis Taklim every Friday in empowering the poor by providing compensation that comes purely from the members of the Majelis Taklim congregation and is given in the month of Muharram, a month full of glory. In addition to compensation activities as a form of social activity carried out by the Majelis Taklim, there are also activities to aid people who get disasters by collecting alms from congregations which will then be given to people affected by the disaster. There are also spiritual coaching activities for people who are sick. Its prof that many who ask for prayer through the activities of this Majelis Taklim, one of which is for those who are sick. Thus, the Majelis Taklim plays a role to fostering the congregation to always set aside their wealth to help others such as compensation for orphans, charity for those in need and spiritual guidance for people who are sick by praying together. --- d. Improvement Economy of Household The Majelis Taklim should play a bigger role in improving the congregation's household economy. However, most of the Majelis Taklim have not played a maximum role in this matter and seem to have burdened the congregation's economy with various consumptive activities. For example, the uniforms used by the Majelis Taklim members who change every year and make pilgrimages that require a lot of money. Therefore, Majelis Taklim needs to form and organize economic activities so that it is hoped that it can improve the congregation's economy, even though they have not been able to provide substantial assistance. However, the case is different with the Majelis Taklim Al-Hidayah of the Curup that is not too burdensome for the economy of the congregation, because in this Majelis Taklim they do not use uniforms in their activities because the member is too many. It means that this Majelis Taklim is general for all people. Although in the annual program of this Majelis Taklim it is always held the pilgrimage of the auliya' but does not force the congregation to follow it. Based on the explanation above, it can be seen that the Majelis Taklim every Friday is not only used as a place to gain knowledge but also plays a role to improve the economy of the congregation by selling, earning the money, and follow the learning about Koran. It is not on the contrary, burdening the economy of the congregation. In the Majelis Taklim are the are many strata of society so that economic turnover occurs of the palce. --- e. The Place to Study Religion There is no doubt that every Muslim must receive religious guidance so that the spirit does not thirst for Islamic values so that they can control themselves and become individuals who are in accordance with the guidance of Islamic teachings. Religious guidance cannot be ignored to create a generation that is mentally strong spiritually, character and faith. Majelis Taklim which built by Muslims must be used optimally to support all activities of their religious life. Human qualities are needed in the future to face increasingly fierce competition in the outside world. Therefore, it is necessary to provide quality education. One of the places where education is held that can help realize this is the Majelis Taklim. The Majelis Taklim is an alternative institution for congregations who do not have enough energy, time, money, and opportunities to gain religious knowledge through formal education. Reach the knowledge is an obligation for Muslims, the existence of the Majelis Taklim is an alternative that allows its existence for all age levels and social strata to study and study religion. Based on the results of interviews above, it can conclude that the main goal of the congregation to attend the Majelis Taklim every Friday is to gain religious knowledge for every people because studying religion is very important. --- f. The harmony of the community Majelis Taklim as one of way fostering Muslims must become a unifying forum for Muslims. The existence of a Majelis Taklim in the community is aimed to increase knowledge and religious beliefs which will encourage the experience of religious teachings as a gathering place to members of the community, as well as fostering and developing religious life in forming a society that fears Allah SWT. Thus, it can be said that the functional role of the Majelis Taklim is to strengthen the foundation of human life, especially in the mental-spiritual of religion and to improve the quality of life integrally, outwardly, and inwardly, worldly and hereafter11 . Based on the explanation of the interviews results, the congregation of the Majelis Taklim, many members follow the forum to study religion and maintaining friendship. Thus, the Majelis Taklim al-Hidayah Curup is expected to become a forum of ukhwah through silaturrahmi so that relationship is established between Muslims fellow, and indirectly can build society in an Islamic life order. To face Islamic life order, it cannot be separated from the religious understanding possessed by everyone. Religious understanding has a very important role for adherents of the religion, understanding the meaning of teaching religious will guide a person to a deep religious appreciation so that the life will be directed. A person's who lack of understanding of teachings religious will less enthusiastic and less focused in carrying out his life, so the strategy is needed to increase the religious understanding of congregations who participate Majelis Taklim. Individual religious understanding is different each period of development. These differences are reflected the thinking and behavior that are influenced by internal, external, or a combination. In childhood, children internalize religious values through observation and imitation of behavior shown by their parents or their closest environment12 . Increasing religious understanding can be seen from how much the religious dimension is applied in the life of each individual. According to Glock and Stark in Kholifah , there are five religious' dimensions . Meanwhile, based on the theory of the religious dimension, it follows: --- 1) Religious Practice Religious Ractice is the degree of a person carries out ritual obligations in his religion. Elements in this dimension include worship, culture, and things that show a person's commitment to the religion adheres to. The practice dimension in Islam can be done by carrying out worship such as prayer, zakat, fasting, pilgrimage, and so on. This dimension is the dimension of worship practice. In this dimension congregations who have attended this Majelis Taklim should show the commitment of worship, for example being obedient in praying or other worship. Based on the answers of the analysis that described above, it show that Majelis Taklim al-hidayah in the Dusun Curup activities is related to the theory of increasing religious understanding to increase religious practice by participating in this Majelis Taklim. --- 2) Religious Belieef Religious belief is called the dimension of belief which is the degree of how far the person accepts things that are dogmatic in his religious teachings. For example, beliefs about God, Angels, Heaven and others that are dogmatic. Basically, every religion wants an element of obedience for every follower, so the most important thing is the willingness to comply to the rules that apply in the teachings of the religion that adhere to. The Majelis Taklim guide to increase religious understanding of the congregation that always comply to the rules of the Islamic religion itself. --- 3) Religious Knowledge Religious knowledge or the dimension of religious knowledge is a dimension that explains how far a person knows about the teachings of his religion, especially those in the Merdeka Ngaliyan Semarang". hlm. 58-60. scriptures and others. At least someone who is religious must know the main things regarding the basics of belief, scriptures, and traditions. This Islamic dimension shows the level of knowledge and understanding of Muslims towards the main teachings of their religion as contained of the Qur'an. This makes a person going by understanding of the contents of the Qur'an. --- 4) Religious Feeling Religious Feeling is a dimension consisting of feelings and religious experiences that have been felt and experienced. For example, feeling close to their God, feeling their prayers answered by God, and other spiritual experiences. In Islam, this dimension can be manifested by build the feeling close and trust to Allah, praying solemnity, gratitude, getting a warning or help from Allah SWT. Based on the speech of narrative of the congregation of the Majelis Taklim every Friday which states that after participating in this Majelis Taklim, the congregation feel that have more gratitude to Allah SWT for the gifts that God has given them. Thus, making every human being calmer and more sincere in carrying out worship to Allah SWT. --- 5) Religious Effect Religious Effect, the dimension that measures the extent to which a person's behavior is consistent to the teachings of his religion in everyday life. This dimension measures the extent to which a person's behavior is motivated by religious teachings in social life. This dimension concerns human relationships with other humans. For example, by helping people who are in trouble, donating their wealth, visiting neighbors who are sick and so on. It conclude from the narrative of the informants, in the Majelis Taklim Al-Hidayah Dusun Curup, it also guides congregation to always donate their wealth to help people who are in trouble. Thus, it can be understood that the Majelis Taklim every Friday teach the congregation to increase the religious understanding to increase member social life which concerns the relationship between one another. --- Conclusion Based on the discussion and analysis of the data presented above, it can be concluded that the Majelis Taklim al-hidayah has an important role to increase the religious understanding of the congregation who attends it. The results of the study are as follows: The role of the Majelis Taklim al-hidayah Curup, Curup Utara sub-district increase religious understanding such Fostering the faith of the congregation. Participating in the Majelis Taklim every Friday make the congregation feels increasing of faith, fostering a family realizing a family Sakinah through recitation activities every Friday, empowering the poor people by holding compensation activities for orphans every month of Ramadan, improving the household economy by selling something in the time they have meeting, as a place to study religious knowledge, the place to increase religious understanding, guide a harmony among the fellow by silaturrahim.

The background of this research is the lack of religion understanding and the practice of religious is not perfect enough. This study aims to describe the role of Majelis Taklim Al-Hidayah to increase religious understanding the which is hold every Friday afternoon. This study uses a qualitative approach because the data which is processed and explained by the description. The data is got by observation, interviews, and documentation method. The sources of this data are primary data sources as the results of interviews to the coaches, administrators, and several members of the Al-Hidayah Majelis Taklim, and secondary data sources derived from activity documentation. The research findings are: (1) After Constructing the congregation's faith, Majelis Taklim the member feels that there is increasing of their faith. ( 2) Fostering families to realizing a Sakinah family through routine recitation activities every Friday (3) Empowering the poor people by holding compensation activities for orphans every Ramadan month. (4) Improvement of the household economy because the member are pilgrims participating in the recitation and selling something. 5. The forum is a place to study religion that can increase religious understanding. 6. Fostering harmony among the people by Silaturrahim.

INTRODUCTION With the change in the epidemiological profile of health problems in early childhood, an increase in the number of children who survive with special healthcare needs , that is, who demand care beyond those required by others in this age group, is emerging. Such care can be developmental, technological, medication and/or usual modified care . In Brazil, the National Primary Care Policy recommends health actions at the individual and collective levels, focusing on family health care in a decentralized manner, to enable access to the entire population. Thus, the Family Health Strategy , which is responsible for organizing and coordinating the interaction between all health services, has the prerogative to ensure the principle of comprehensive care . Contradictorily, in many realities, the organization of health services is defined by intense fragmentation and the current care model does not correspond to changes in the epidemiological profile of the Brazilian population, given the rise of chronic diseases . It is in this scenario of disarticulation that CSHN and their families are inserted. Regarding the scope of primary care, the precarious structure to receive them and the lack of home care stand out . Added to this, the daily struggle faced by these families to ensure the rights of their children, in the face of a fragile and disjointed care network . --- OBJECTIVES To discuss the visibility of children with special healthcare needs and their families in the Primary Health Care scenario. --- METHODS This is an experience report developed based on situations experienced by nurse researchers from different regions of the country when seeking to identify and contact CSHN within the scope of Primary Health Care for the development of research. It should be noted that, initially, the researchers experienced this difficulty in isolation, as a specific reality of the municipalities where the studies were carried out. However, when discussing the results of their studies in scientific events and presentation of thesis and dissertation to board members, they found similarities of difficulties and challenges faced -in different scenarios and regions of the country -to locate this clientele within the PHC scope. Thus, they realized the need to report their experiences to discuss the issue, giving visibility to it. In methodological terms, first, all the researchers reported and converged their main difficulties in identifying CSHN and their families within the PHC scope, their strategies to locate them and, after finding them, what were the main reports presented regarding the care received. Subsequently, they discussed the impact of the lack of follow-up in PHC, as well as proposed measures to bring sense to managers and health professionals about the importance of these children and their families being assisted, monitored and supported at this level of care in favor of integrality, longitudinal and equity care. It is noteworthy that the results reported here come from studies carried out with CSHN independently in the course of the development of research projects in the municipalities of Maringá-PR, Santa Maria-RS, Ribeirão Preto-SP and Campo Grande-MS. All of the studies were submitted to the Research Ethics Committee of their respective institutions, in compliance with Resolution 466/2012 of the National Health Council. --- RESULTS --- Strategies to identify children with special health needs in primary care In PHC, there is no systematic method for the registration of CSHN that makes it possible to know how many and where these children and their families are placed, since the registration and monitoring forms of families in primary care have only the indication of disability -which refers to a long-term or permanent physical or mental condition. In this way, all the researchers, in the different states of the country, went personally to the health units to talk to survey assisted CSHN. However, despite the complexity and demand for care that this population requires, it was observed that, in most cases, specific monitoring was not offered to these people in the primary care service checked for the research. Besides that, in some cases, the existence of these children was unknown in the coverage area, except for some isolated reports by community health agents who knew the population because they lived in the community. One of the experiences took place in a study carried out in Maringá-PR , in which the researchers contacted all nurses or coordinators of the 29 Basic Health Units in the city and, also, informal conversation with community health workers of the 62 FHS teams. At this time, they requested the indication of children residing in the area covered by the Unit who would be able to be included in the study because they have special needs for continuous/complex care. In a study carried out in Ribeirão Preto-SP, there was also contact with 46 PHC units in search of an indication of CSHN in the coverage area, in addition to displaying posters in the Units and dissemination in the news . In the double-center study carried out in Ribeirão Preto-SP and Santa Maria-RS, after finding that professionals were unaware of these children and/or confused them with others with Down syndrome, for example, an active search was carried out with a screening of all children attended for any reason at BHU . In Campo Grande -MS, due to the difficulty in spotting the CSHN in PHC, the researchers had the support of referrals made by a public hospital and a special education and rehabilitation institution . However, although communication media were used, such as folders and posters, to explain the characteristics presented by these children, the survey of the CSHN attended at the PHC was not effective, as there was little control and registration of such visits. Also, when some type of record was found, it was from the material dispensing book of the warehouse. It is highlighted that the CSHN terminology, used here, has its concept in the academic group and it was detailed to professionals, aiming to explain which children could be included in this definition according to guidelines of a specific instrument for identifying this clientele, namely: to have some drug dependence for at least 12 months, need for follow-up in of visibility of children with special health needs and their families in primary care Marcon SS, Dias BC, Neves ET, Marchetti MA, Lima RAG. specialized services and physical limitation. If the child has at least one of these characteristics, it is considered a CSHN , as it requires greater support from health care networks, educational services and social assistance. Given these primary difficulties, the researchers established new strategies, such as, the active search in non-governmental support institutions in the municipalities of Maringá and Campo Grande and the application of the snowball method. This method was adopted in a study carried out in Ribeirão Preto and allowed the identification of 102 CSHN in that municipality. In Maringá, the CSHN were spotted with the support of an educational and rehabilitation institution, which, in contrast to the PHC that had indicated 27 CSHN, identified 91 enrolled CSHN, showing a great discrepancy concerning the number of children monitored by the PHC. In Campo Grande, most of the spotted families attended the referral of professionals and accepted the invitation to participate in the study. Even other families, who later heard about the study, spontaneously sought information and actively participated in the activities. This shows the lack of intervention and the gap in assistance to these families. --- The experience of families concerning PHC services After facing adversities to identify CSHN in the community, the researchers finally accessed the family's experience in this type of care and identified similar reports regarding PHC services. The authors of the studies carried out in Ribeirão Preto and Santa Maria, for example, identified, through the reports of family members, that the CSHN were not monitored by PHC in a systematic way regarding the PHC attributes -longitudinal and coordination of care, because, many times, exactly because they had a chronic condition, they were guided to seek assistance directly in the emergency services or specialized outpatient clinics. Likewise, the study carried out in Maringá found that of the 68 participating CSHN, 40 were not visited by any member of the FHS team, 21 were visited only by the CHW and only seven reported that they were, in fact, followed-up by the FHS team. Also, the reports showed that in the face of some health problems, the child was not considered a priority when scheduling medical appointments, raising the need to seek emergency care services and/or even hire private health insurance . In the study conducted in Campo Grande-MS, the interviewed families reported not using the BHU because they considered that the professionals did not direct interventions to their reality and were disinterested in their needs. They also reported that the units did not guarantee priority access due to the child's special condition and that actions directed at the child and/or the family were not developed by the team, except for immunization and general guidelines. Thus, they perceived themselves as distant from health professionals, especially from the BHU. Besides, they assessed that the information and guidance received, since the child's diagnosis, did not clarify or assist in the management of home care. According to some reports, the BHU team adopts a family responsibility attitude when the child has an aggravated health situation, which intensifies conflicts and increases the distance in the interactions between the team and the family, who do not feel supported in their challenges with the child . --- DISCUSSION Children included the study had chronic conditions, with important implications for their growth and development. They also needed health technologies to keep the activities of daily living, and the main caregiver usually was a member of the nuclear family, most often, the mother. Children who have progressive, incurable, disabling diseases, need continuous pediatric care, to control symptoms and ensure monitoring in psychological, emotional and spiritual aspects, including their families . It is noteworthy that the work of primary care with these families allows them to be properly guided to provide care and, consequently, to avoid health complications, in addition to promoting the use of basic assistance resources. Communication between the family and the health service to assess what are the real needs to be assisted helps in practical aspects and the elaboration of care plans, in addition to providing quality of life, despite the experience of chronicity, and assisting in case of family experience the suffering process . It is noteworthy that, although it is a subject little discussed, families, in a way, already experience a process of mourning for the unhealthy child, that is, this experience is invaded by the insecurity of the longevity of the lives of children with special healthcare needs. The little knowledge or knowledge of community health workers about these children, despite living in the area covered by their FHS team, demonstrates a failure to comply with what is recommended by the National Primary Care Policy , since all families belonging to a micro area must be registered and have their records updated frequently. In a study carried out with CHW on the perceptions about their performance in the FHS, the authors found that they did not recognize the mapping and registration of families as attributions of their position . It is recommended that nurses, as one of their roles, provide comprehensive assistance to families at home when they are unable to attend the UBS . It is emphasized that the recognition of the specificities of the role of each member working in the FHS is central to their performance and ensures that assistance to families is carried out with quality. In a survey conducted in western Paraná, nurses reported that service to users tends to be limited when work is not performed by all team members. Thus, everyone who makes up the FHS team needs to act mutually and cooperatively so that care is longitudinal . In this sense, the FHS could count on the participation of the Family Health Support Center, to propose care actions directed to children with special needs for multiple, complex and continuous care, as well as to their families. The home visit allows professionals to know the family's socioeconomic context, their home care practices and the needs for intervention, support or guidance. Thus, they can prepare the family for a more effective and less arduous activity and promote the health of all family members . A study that aimed to understand how the accessibility of children with disabilities in primary health care is, from the perspective of the professionals from the FHS team, found the lack of transportation as one of the difficulties faced by the team to carry out home visits . This difficulty, however, does not justify the fact that such families are not located and assisted in their needs. --- of visibility of children with special health needs and their families in primary care Marcon SS, Dias BC, Neves ET, Marchetti MA, Lima RAG. The poor awareness of health professionals about the operation and activities carried out in institutions that provide specialized monitoring to these children, such as the Associação Norte Paranaense de Reabilitação , in Maringá-PR is highlighted . In practice, these institutions end up taking responsibility for the care and monitoring of the health and development of CSHN, including activities in the pedagogical field. The guidance and monitoring of the general health of the child and their families must be carried out by the primary care services, and it is up to the professionals of the FHS team to know the demands of the child's care, as well as their monitoring needs to prevent diseases. However, these professionals are unprepared for the care of children with disabilities, such as the assistance necessary referrals for therapies that contribute to their development . Also, the information they send to the family is not always compatible with their needs or degree of understanding, making them anxious, confused and with the feeling of being disrespected, which contributes to not being able to take actions or make decisions in the face of demands child care . As of 2008, the Chilean Society of Pediatrics began to use the terms Niños y adolescentes com necessidades especiales de atención em salud instead of the term chronic illness . In this sense, authors believe that special attention from the public health system is necessary, developing health care at the primary, secondary and tertiary levels, respectively, seeking to ensure comprehensive health care for this group and magnify the use of the features available in the health network . According to this model, PHC teams are responsible for assisting children who need assistance considered to be of low technology -those who have a stable clinical condition, with families equipped to provide care. CSHN who need assistance considered to be of medium technology -stable, but who require specific care and are committed to carrying out their daily activities -must be followed up by the secondary health level, who are directed to a health reference center and accompanied by a family health doctor. On the other hand, children that demand care of high technological density, depend on tertiary care, requiring assistance from a multidisciplinary team. Thus, the model proposes that there is a coordination of the care provided to children and families, highlighting the nurse as an articulator . In Brazil, support networks for children with special health needs are fragmented and weak . Public support policies specific to this population could be implemented if there were knowledge of the number of children in the country, if the families were enrolled and systematized in the health services and if there was effective communication between the support networks. In this way, when the child was discharged from the hospital, he/ she would be immediately referred to the primary care service, which would be responsible, together with the family, for the continuity of care at home. A study carried out in southern Brazil showed that health care networks need to be integrated and articulated to better serve children with special health needs, as PHC is unaware of the needs of the child's chronic condition. This sometimes hinders preventive measures from being designed and implemented to avoid complications that cause the repeated hospital readmissions that affect these children . In Canada, health care and rehabilitation institutions seek to meet the demands of children with special healthcare needs and their families to support the therapeutic plan based on Family-Centered Care . Thus, this approach recognizes the family as the main holder of care for the sick person and advocates that it influences on the health of the person being cared for. This model recommends the inclusion and participation of the family in the elaboration and implementation of care plans for the sick family member, in addition to considering them the protagonist of care, giving them autonomy to decide what their needs are. Besides, it assists to all members of the family system, preventing overload and future injuries . In Brazil, the Home Care Service acts as a complementary aid for hospitalization, by training caregivers to carry out activities with the sick person and to expand the autonomy of users, with the support of Multiprofessional Home Care Teams and Multiprofessional Support Teams . However, carrying out this service is still restricted to a few locations in the country and, in many areas, children and adolescents are not included in the HCS. PHC can be an important ally of families of CSHN, considering their potential to play the role of organizer of the care network and coordinator of care . Still, it is possible to develop familycentered care, promoting the bond between the family-team to ensure longitudinal care. --- Limitations of the Study We highlight as a study limitation, the fact of presenting the report of the difficulty to locate/find children with special healthcare needs in only four Brazilian municipalities. However, as these are located in different states and regions of Brazil, it is inferred that this situation may be similar in other scenarios. --- Contributions to Health and Public Policies We expect this report will contribute to giving visibility of CSHN and their families in the context of primary care, as well as their care demands in official rates and for the implementation of public policies. With this visibility, it is expected that the chronification rates of these children's health status and the rates of frequent hospital readmissions may be reduced. --- FINAL CONSIDERATIONS The experience of an active search for children with special healthcare needs in PHC in four municipalities in different regions of the country showed that these, in their majority, are little known by the professionals who work with this type of assistance and, therefore, do not appear in statistics based on the reality of these services. In this document, the use of the word visibility in the dialectic thinking is highlighted, as it is believed that CSHN, who are although visible to PHC services, are often made invisible by the feeling of not belonging and the search for specialized services, as reported by families themselves. Thus, in practice, there is a kind of transfer of responsibility for the care and monitoring of these children's living and health conditions to specialized and rehabilitation institutions or even of visibility of children with special health needs and their families in primary care Marcon SS, Dias BC, Neves ET, Marchetti MA, Lima RAG. by private health plan operators. This favors the unfamiliarity of the care demands of this group and the appreciation of care centered on disease and rehabilitation, in contrast to the longitudinal care, one of the attributes of primary health care. This way, it is concluded that the integrality of the actions and the guarantee of continuity of care constitute challenges to be overcome by the families of CSHN, since they access the PHC network at the time of diagnosis and, after, they have not ensured the continuity of follow-up in health adequately, as PHC understands that this child needs follow-up in specialized services, often geographically distant from their homes. The implementation of actions in a systematic way with records and monitoring of these children will enable families to have greater access to primary care services and even greater resolution. However, for this to occur, it is necessary that health professionals, especially those who assist in PHC, are committed to recognizing who these children are in their territory and are concerned with offering them qualified care. Their health care needs must be known, as well as a link with families and accountability to effectively follow-up these children in favor of comprehensive care.

Objectives: to discuss the (in)visibility of children with special healthcare needs and their families in the Primary Health Care scenario. Methods: experience report about the difficulties faced by researchers from different regions of Brazil to locate children with special healthcare needs in the scope of primary care. Results: the main reason for these children and their families to be "unknown" and, therefore, not assisted in PHC, is the fact that they are followedup by institutions/outpatient clinics and specialized and/or public rehabilitation clinics, or even because they have private health insurance. Final Considerations: transferring care responsibility to the Primary Health Care teams to specialized and rehabilitation institutions may be related to the lack of knowledge of the care demands of this group, as well as to the relevance of care centered on rehabilitation and the specialty instead of the long-term care, one of the features of primary health care.

Introduction Disruptive behavior problems are the most common presenting problems for children entering mental health care [3]. These problems are associated with several different diagnoses, and children with these problems are at elevated risk for a variety of maladaptive outcomes including serious mental illness and incarceration in adulthood [4]. There are more evidence-based treatments for these problems than for other childhood mental health conditions [5]. Unfortunately, racial and ethnic minority youths are less likely than non-Hispanic White youths to receive these treatments given evidence of significant disparities in service access, use, and intensity [6][7][8][9]. These disparities in mental health care have not been explained entirely by potentially confounding factors such as family income, insurance coverage, or clinical need [7,10], suggesting that there are many additional influences that need to be identified and addressed in order to ultimately reduce these disparities. Racial/Ethnic Disparities in Children's Mental Health Care While there is unmet need for mental health care for all children, numerous studies indicate that unmet need is significantly greater for racial and ethnic minority youth compared to non-Hispanic White youth [6][7][8]. Evidence suggests that African American, Latino, and Asian American youth are less likely to enter mental health care and even after entering care, youth from racial/ethnic minority groups obtain fewer and/or less intensive services [7,11,12]. Reducing these disparities in mental health care is a national priority and efforts to reduce disparities require accurate and comprehensive data identifying disparity determinants. Raphael and Beal have proposed a useful conceptual framework to guide disparity research that identifies potential determinants of disparities at multiple levels ranging from the individual level to the health systems , community, and societal levels [13]. In children's mental health care, much of the research has addressed individual factors, with important emerging research identifying culturally driven beliefs about mental illness and help-seeking preferences that may partially explain service disparities [14,15]. Additional research has identified sociodemographic factors that are associated with service use [10,16]. However, very little research has been conducted on how factors at the health systems level, especially provider attitudes or behaviors, influence service use for diverse patients. Given that individual/family factors do not entirely explain disparities in mental health services [7], research on potential determinants at other levels in the Raphael and Beal framework is needed [13]. To complement existing research at the individual and family level, this study examines potential determinants of disparities at the health system level by examining how provider decision-making on diagnosis and treatment recommendations may vary based on patient race/ethnicity. While providers' decision-making has been scarcely examined, the limited research available suggests there may be bias in diagnostic decision-making by patient race/ethnicity in the mental health field. Studies of provider assigned psychiatric diagnoses reveal prevalence differences by race/ethnicity, with children of color more likely to be diagnosed with psychotic disorders and non-Hispanic Whites more likely to be diagnosed with mood disorders [17][18][19]. Given that there is no convincing evidence to support a valid racial/ethnic difference in prevalence of these disorders [11], bias in clinical decision-making is suspected. In a large national study, investigators found that African American youth were less likely to be identified with internalizing psychiatric disorders compared to non-Hispanic White youth [11]. Research on adult mental health also provides some evidence for potential bias. For example, Strakowski and colleagues found that mental health providers are more likely to attend to symptoms of psychosis for African American men compared to non-Hispanic White men when all other factors are controlled [20]. Thus, the limited research on potential influence of patient race/ethnicity on physician diagnostic decisionmaking suggests that there may be an effect, but this has not been well tested for childhood behavior problems. Racial disparities in physicians' psychoactive prescription patterns have also been identified. In one study of adult Medicaid beneficiaries, physicians prescribed newer atypical antipsychotic medications to non-Hispanic Whites more frequently compared to African American patients for whom they were more likely to prescribe traditional antipsychotics [21]. Race/ethnic differences in psychoactive medication use among children have been relatively well documented. Specifically, numerous studies have reported higher rates of psychoactive medication use among non-Hispanic White children and adolescents compared to racial/ethnic minority youths [9,16,22]. In our previous study of communitybased mental health care for children with DBPs, we found that two thirds of children ages 4-13 used psychoactive medications, but racial/ethnic minority youths were significantly less likely than non-Hispanic White youths to utilize these medications, even when controlling for potentially confounding factors [16]. In fact, family ethnicity was a more robust predictor of medication use than were clinical factors such as the child's diagnosis or behavior problem symptom severity. However, the extent to which these disparities in service use are driven by patient access, patient preferences, and/or provider treatment recommendation decisions is unknown. Most of the research examining determinants of racial/ ethnic differences in psychoactive medication use among children has examined factors such as insurance coverage or differences in patient and family treatment preferences. For example, Yeh and colleagues have found that ethnic minority parents of children with mental health problems are less likely to endorse biopsychosocial beliefs about the causes of emotional and behavioral problems, and correspondingly, they report less positive attitudes than non-Hispanic Whites about the potential benefits of biopsychosocial interventions, such as psychoactive medications [23]. Research in the adult physical health care domain suggests there may be complex interactions between patients' beliefs and preferences, providers' perceptions of patients' preferences , and provider clinical decision-making. Specifically, van Ryn and Fu hypothesize that provider beliefs about patients influence their interpretation of symptoms, which subsequently influence clinical decision-making [24]. This hypothesis is supported by their earlier research indicating that physicians' perceptions of patients' resources and/or attitudes predicted their treatment recommendations. The extent to which physicians may be making assumptions about patients' resources and attitudes based solely on their race is unknown. However, physicians were more likely to rate African American patients as lacking in social support and as more unlikely to participate in treatment compared to non-Hispanic White patients [25]. Yet independent of race, physicians' perceptions of patients' education and physical activity preferences were significant predictors of treatment recommendations [26]. Tamayo-Sarver and colleagues found that "socially desirable patient characteristics" associated with occupation, relationship with primary care doctor, and reliability of follow-up were significantly associated with opioid prescription rates, but race/ethnicity was not [27]. These mixed findings support the need for further investigation of the role of provider clinical decision-making as a determinant of health care disparities, and specifically, the extent to which patient race/ethnicity may drive clinical decision-making. Given the complex interactions between provider and patient that influence provider clinical decision-making, there is a great need for studies of provider behavior that can control for patient characteristics to test specific effects. Analog or mock patient presentations are used frequently to assess clinical decision-making for education, evaluation, and research purposes because these methods allow for control over patient variables. While there are potential limitations to this method and the extent to which one can be certain that provider decision-making based on mock stimuli reflects decisionmaking in actual practice, this method has significant advantages for research as it allows for standardization and experimental manipulation to test hypotheses. Several health care studies have effectively used vignettes as stimuli to elicit clinical decision-making outcomes. For example, Epstein and colleagues used videotape vignettes to examine physician characteristics associated with clinical decisions regarding treatment for depression [28]. They found that several physician characteristics were significantly associated with quality of care indicators. Burk and Sher also used videotapes of adolescents to examine the impact of family history of alcoholism on mental health workers' assessment of diagnosis and predicted psychopathology [29]. In a study most closely reflecting the general aims of this study, Tamayo-Sarver and colleagues used text vignettes with color face photos depicting patients of different races, to test for differences in emergency room physicians' prescription patterns as noted above [27]. --- Children with Disruptive Behavior Problems The clinical problem area selected for this study is disruptive behavior in childhood because the vast majority of children entering public mental health care present with these types of problems [3]. Children who present with significant disruptive behavior problems may meet criteria for a variety of psychiatric diagnoses and there are multiple evidence-based psychosocial and psychopharmacological interventions for these patients. Behavioral parent training approaches, parent-child interaction therapies, and problem-solving skill training for children are a few of the most well-established evidence-based practices for these problems [30]. A variety of psychoactive medications are also used frequently for these patients. In fact, a national study indicates that the most common problem category for children receiving psychoactive medications in the USA is DBPs [31] and national "best practice" recommendations include prescription of psychoactive medications for these youths [32]. Efficacy research data offer promising support for the use of psychoactive medications for children with DBPs, particularly stimulant medication for children with attention and hyperactivity symptoms, which often occur concurrently with other DBPs [33]. The majority of children treated with stimulants for ADHD show a positive response [34]. However, several studies indicate that non-Hispanic White children are much more likely to use these medications than are children from racial/ethnic minority backgrounds [16,35]. The role of physician prescription patterns in driving these differences is unknown and is a major focus of this study. There is significant national attention to the increased use of psychoactive medications for children [10,36] with public controversy about rising rates of use of psychoactive medications for children, including increasing rates of polypharmacy [31] and potential health risks. Several medications are recommended as "best practices," but there is considerable debate about potential over-and/or under-use and concern about unintended effects of several different psychoactive medications used to treat DBPs in childhood. There are specific concerns also about the dramatically rising rates of the use of atypical antipsychotics for children with a variety of behavioral problems and the physical health risks associated with these medications [31]. Within this debate, there has been limited attention to the role of racial/ethnic disparities in medication use, but such attention is highly relevant as it addresses potential factors other than clinical need that may be influencing utilization. Thus, studies of factors driving medication utilization are timely. The clinical problem area of DBPs provides an excellent focus for research on providers' clinical decision-making on medication because it is so common that all providers should have some knowledge and opinions, as well as experience; and while there is some consensus on diagnosis and recommended treatments, there is enough ambiguity regarding a range of potentially diverse treatment options to yield sufficient variability for study. The primary aim of this study is to test for differences in physician diagnostic and treatment decision-making associated with patient family race/ethnicity ) holding other factors constant . Given the documented disparities in psychoactive medication use by patient race/ethnicity, the primary hypothesis is that physicians will be more likely to recommend prescription of psychoactive medications for NHW patients compared to African American and Hispanic patients even when other client characteristics are held constant. --- Research Methods Methods for this study were developed and piloted by a collaborative group of investigators and practicing physicians supported by a collaborative planning grant from the UCSD Division of Child Development and Community Health within the Department of Pediatrics. Methods are described below in two phases: phase 1-development and pilot testing of clinical vignettes and survey measure; phase 2-implementation of national web-based physician survey. The study was approved by the university's human subjects committee. --- Phase 1: Clinical Vignette Development The goal was to produce three clinical video vignettes that differed only by race/ethnicity of the actor and represented common clinical presentation in community care, and sufficient ambiguity in diagnosis and treatment recommendations to elicit variability in physicians' decisions on the key outcome variables . A script for the vignette actors was developed collaboratively based on provider input . The video vignette portrayed a mother reporting on her child's symptoms and functioning, as well as some contextual information as described below. Specifically, the child's reported symptoms met DSM-IV criteria for oppositional defiant disorder plus some ADHD symptoms that were sub-threshold for diagnosis, to reflect the overlapping symptoms typically occurring in DBP populations. The vignette presentation included controlled descriptive contextual data about the child, including age, gender, grade and performance in school, as well as data on family composition, school, and social functioning. The vignette also stated specifically that the family had optimal health insurance to cover treatment and that they were open to all treatment recommendations, controlling for treatment access and family motivation. The vignettes varied only by race/ethnicity of the parent . Dozens of potential actors were screened . A total of eight actors were interviewed and screen tested to control for other potentially confounding variables such as age, articulateness, general attractiveness, and eye contact. Three actors representing each race/ethnic group were selected for final taping and video production. Each of the two subsequent actors watched the first video that was filmed and were instructed to match the pacing and emotional expressiveness. External factors such as clothing, jewelry, and scenery were standardized across vignettes. Several "takes" were conducted until a vignette was judged to be equivalent to the others. Videotaping and production was conducted by a professional Visual Media Group and all video was shot in high-definition. The three final vignettes were distributed to 12 independent physicians for pilot-testing to rate each vignette actor on "articulateness," "believability," and "attractiveness" and to confirm intended race/ethnic representation. Viewers confirmed the intended race/ethnicity of the actor and used a 1-4 Likert scale to rate the constructs listed above. These ratings were used to assess the extent to which all three presentations were equivalent on factors that may influence physician decision-making. Mean ratings across all three race/ethnicity vignettes were within .25 points on all three constructs and thus determined equivalent. Equivalence across videos was considered essential to the study design to test for a specific isolated effect of patient race/ethnicity on physician decision-making. Phase 1: Survey Development Survey questions were developed by the collaborative group and refined based on piloting with practicing physicians. Three focus groups were held with local physicians to generate feedback on diagnostic and treatment planning challenges and factors that impact diagnostic and treatment planning decisions. Members of the focus groups were also asked to complete the survey and provide feedback on comprehension and feasibility. The content of the 20-item final version of the survey can be characterized by five sections: demographic information, patient characteristics, clinical vignette presentation, diagnostic assignment, and treatment recommendations. Demographic questions assessed age, gender, race/ethnicity, medical school location, years in practice, medical specialty, practice setting, and location. Patient characteristic items assessed proportion of the physician's practice population that were pediatric, racial/ethnic minorities, unfunded/publicly funded, and had mental health or behavioral presenting problems. Diagnosis items asked respondents to select any DSM-IV diagnoses that should be assigned to the child described in the vignette. Possible responses included ADHD, anxiety disorder, autism spectrum disorder, bipolar disorder, conduct disorder, depression, disruptive disorder not otherwise specified, intermittent explosive disorder, oppositional defiant disorder, substance abuse, and none. The specific diagnostic categories selected were based on prevalence of diagnoses assigned to children with disruptive behavior problems. Treatment questions asked physicians if they would recommend psychosocial/ psychotherapeutic treatment , and/or psychopharmacological treatment , and if yes for either category, asked for selection of specific type of treatment from a range of options. Respondents also had the option to select "no" treatment or alternative holistic or complementary medicine treatments. --- Phase 1: Web-Based Survey Procedures A variety of web-based survey software options were reviewed and SurveyGizmo was selected. This platform was selected due to the innovative survey technologies, including the ability to embed streaming media, support random assignment of video vignette conditions using sophisticated branch logic techniques, and conversion of inputted data to a readable SPSS export for analysis. Viddler Video Platform was used for encoding, storing, and delivering the video vignette through SurveyGizmo. It was selected for its ability to host streaming video in MAC or PC formats, with full mobile iOS and Android device support to ensure reliable delivery to a wide variety of respondent conditions. Additionally, Viddler is a secure video host and prevents respondents from copying or tagging the video for sharing on social media sites. Survey items were built into the web-based software and tested multiple times using a random response generator. This function creates hundreds of responses to the survey and aids in the identification of faulty skip logic, problems with text fields, and errors with encoding of streaming video. In addition to the random response testing, a small sample of physicians completed the web-based survey prior to launch of the national survey to test for functionality of email invitation, email embedded survey link, and streaming video vignette. These participants were also asked to note total time to completion of the survey, clarity of items, instructions, and skip logic patterns. --- Phase 2: National Web-Based Survey Administration --- --- Procedures Participants were recruited in two waves of 4,000 each . Wave 1 physicians were sampled midweek and a follow-up reminder was sent 7 days later. Sampling procedures for wave 2 were exactly the same and began 1 month after wave 1. The invitation included a brief general description of the study purpose as a study of provider practices and description of the general task . Clicking on the hyperlink to the survey took respondents to the Informed Consent page of the survey. Respondents were notified that advancing beyond the Informed Consent screen constituted an electronic signature to participate in the research project. Upon consenting, participants were asked basic demographic and patient characteristic questions, followed by viewing one of the randomly selected video clinical vignettes of approximately 2 min duration. The random assignment of video vignette conditions was set to approximately 33 % for each video. The final distribution was Hispanic 31 %, African American 33.2 %, and non-Hispanic White 35.8 %. The survey questions assessing diagnostic and treatment decision-making followed the vignettes. Upon completion of the survey, respondents were offered the opportunity to register for an online Amazon.com gift certificate delivered to their email address of choice. --- Data Analysis Data analysis included basic descriptive data on participant characteristics and response frequencies to diagnostic and treatment recommendation survey questions. Primary --- Results Total Sample: Diagnostic and Treatment Decision-Making --- Diagnostic Assignment Table 2 lists all the frequencies for the total sample and the frequencies within each of the groups by race/ethnicity of the mother in the clinical vignette. Across all respondents, the frequency of diagnostic assignment was as follows in order of frequency: ADHD 61.7 % ; oppositional defiant disorder 48.2 % ; mood disorder 37.5 % ; conduct disorder 21.0 % . Eleven percent of the participants endorsed "no diagnosis," 28 % endorsed one diagnosis, and 60.9 % endorsed two or more diagnoses. As indicated in the "Research Methods" section, the vignette was designed to report symptoms meeting diagnostic criteria for ODD and sub-threshold symptoms of ADHD. --- Treatment Recommendations The vast majority of respondents indicated that they would recommend psychosocial or psychotherapeutic treatment. The most commonly recommended types of psychosocial treatment were individual child treatment , family therapy , and parent training . A minority of respondents recommended group treatment, and mental health treatment for the parent only as the specific treatment choice. These recommendations were not mutually exclusive and the majority of respondents selected more than one psychosocial treatment option. A smaller majority of respondents indicated that they would recommend pharmacologic treatment. When queried to specify what type of medication, 46.1 % endorsed stimulants, 17.5 % antidepressants, 8.9 % mood stabilizers, and 4.9 % other medications which included atypical antipsychotics and "non-stimulant ADHD medication" . These choices were not mutually exclusive; 44.1 % of respondents endorsed one medication, and 16.3 % endorsed two or more. Among the respondents who indicated that pharmacologic treatment was not indicated , when asked for a reason, the majority endorsed that they would "Want to try other interventions first." Other responses endorsed by multiple respondents were "Medication is not indicated for this diagnosis" and "Risks of medication outweigh potential benefit" . Finally, 7 % of respondents recommended a school intervention and 3.5 % recommended a holistic health intervention. . --- Testing for an Effect of Patient Race on Diagnosis and Treatment Planning --- Diagnostic Assignment Chi-square tests were run to test for a group difference on rate of endorsement for any of the diagnostic options , oppositional defiant disorder, none). There were no significant findings on any of these tests . To further explore any potential effects, the disruptive behavior diagnoses of conduct disorder, ODD, and disruptive disorder NOS were combined into a disruptive behavior disorder category. The Chi-square test on this distribution did not approach significance . --- Treatment Recommendations The very high rate of recommendation for psychosocial treatment overall was consistent across the race/ethnic groups; thus, there was no significant group difference . Virtually all physicians recommended psychosocial treatment regardless of which clinical vignette they viewed. There was greater variance in specific types of psychosocial treatment as noted in Table 2, but there was no significant group difference in rates of recommendation for these types of psychosocial treatment . There was variability on recommendation of psychopharmacological treatment with an overall rate of endorsement of 60 %. As noted in Table 2, among respondents who viewed the Hispanic vignette, 55.2 % recommended medication, among those viewing the African American vignette, 63.9 % recommended medication, and among those who viewed the non-Hispanic White vignette, 61.4 % recommended medication. These rates of endorsement did not represent statistically significant difference by group . There was one significant group difference on recommendation for anti-depressant medication. As noted in the summary table, anti-depressants were recommended more frequently for the non-Hispanic White patient , compared to the African American and the Hispanic patients . There were no significant group differences in frequency of recommendation of the stimulants or mood stabilizer medications . --- Exploratory Follow-up Analyses We conducted follow-up analyses to explore for physician characteristics that may have been associated with treatment recommendations. There were significant differences in treatment recommendations based on physician specialty. Specifically, psychiatrists were more likely to recommend pharmacological treatment compared to the Family Medicine and Pediatric physicians. Specifically, 72.5 % of child and adolescent psychiatrists, 67.5 % of general psychiatrists, 54.0 % of Family Medicine physicians, and 50.5 % of pediatricians recommended psychoactive medications. Exploratory three-way analyses to text for any effects of patient race/ethnicity by physician specialty for recommendation of psychopharmacology treatment did not reveal any significant effects. In addition, male physicians were significantly more likely to recommend medication compared to female physicians, but the specialty differences held within gender groups. --- Discussion This study was designed to investigate whether and how patient race/ethnicity may affect physician diagnostic and treatment decision-making for children with disruptive behavior problems when other factors are controlled. Results of this national web-based survey of physicians likely to care for these children did not reflect evidence of major differences in diagnostic or treatment decision-making based on race/ethnicity of the patient's mother. Given the well-documented race/ethnic disparities in mental health service use, the authors expected to find a corresponding effect on physician decision-making for treatment. However, as multilevel models of health disparities emphasize, health service use is affected by many interacting factors. Race/ethnic disparities in mental health service use are likely attributed primarily to factors such as socioeconomic factors [8], family help-seeking attitudes and beliefs [37,38], and funding or policy level factors [39]. Emerging support for the significant impact of funding level factors comes from studies demonstrating that race/ethnic disparities in unmet need decreased when insurance coverage is expanded in programs such as SCHIP [40]. The mostly null findings in this study could also be interpreted as promising evidence that physicians' decisionmaking is not significantly influenced by race/ethnicity when other clinical and family context variables are held constant . For example, in another study examining the role of adult patient race/ ethnicity on decisions to prescribe medication, investigators found that patient characteristics such as occupation and perceived reliability with follow-up were more significantly associated with physician decision-making than the patient's race/ethnicity [27]. Almost all the research on race/ethnic disparities in children's mental health services has examined actual service use. Studies which test for race/ethnic differences in referral to services have, like the present study, demonstrated somewhat unexpected results. Some studies have found race/ethnic differences in mental health referral patterns for at-risk youth [41]. However, like the current study, one recent large national study examining the role of referral pathways in driving disparities in youth mental health service use also resulted in unexpected null findings across most analyses [11]. Specifically, the authors expected to find a significant racial/ethnic difference in identification of mental health problems and encouragement to seek services, but they found virtually no significant differences. The study included data on a nationally representative sample of 6,112 adolescents from across the USA and thus had more than adequate power to detect significant effects. The authors attributed the null findings to potential regional differences that may be obscured in the national sample and to changes over time in professionals' recognition of mental health problems across race/ethnic groups. They speculated that professional education efforts over recent decades may be decreasing biased or differential interpretation and recognition of behavioral health problems based on race/ethnicity, which is also a potentially reassuring hypothesis [11]. --- Physician Decision-Making for Children with Disruptive Behavior Problems Despite the generally null findings related to the influence of race/ethnicity on physician decision-making, the descriptive findings are important. The range of responses to diagnostic assignment and treatment recommendations fell generally within predicted patterns for the clinical vignette stimuli. However, only approximately two thirds of the respondents assigned a disruptive behavior diagnosis to the child and only 48.2 % assigned the specific disruptive disorder that the vignette was designed explicitly to meet. The majority of respondents assigned the diagnosis of attention deficit hyperactivity disorder, although the vignette did not include enough symptoms to meet diagnostic criteria. Many respondents assigned diagnoses of depression or bipolar disorder . Although the vignette did not directly reflect symptoms of these mood disorders, irritability is a valid symptom criterion for depression, so this is not entirely surprising. This variability in diagnostic assignment is consistent with other studies documenting a lack of reliability and consistency in mental health diagnoses for children across reporters and/or diagnostic assessment methods [33,42,43]. Respondents' treatment recommendations were generally consistent with recommended best practices. Specifically, the majority of respondents recommended individual child psychotherapy, family therapy, and/or parent training therapy, and there are evidence-based treatment models for this patient population reflecting each of these approaches [5,30]. The psychopharmacological recommendations were also generally consistent with evidence-based approaches, with stimulants being the most common. It is notable that over 15 % of physicians recommended two or more psychoactive medications for this patient , reflecting some concerns that have been raised regarding increased rates of polypharmacy use in young children. Although studies of medication use in children with behavior problems identify rapidly rising rates of use of atypical antipsychotic medication , very few physicians indicated they would prescribe this medication. The exploratory findings in this study, demonstrating that physicians trained in psychiatry were more likely to recommend medication compared to primary care physicians, are also not surprising given greater training and experience for the psychiatry specialists. The observed gender differences are also interesting, but somewhat confounded by specialty differences given an imbalance in the primary care fields versus psychiatry. Finally, there was one lone statistically significant race/ ethnic effect on recommendation for antidepressant medication and the results were consistent with the study hypothesis. Frequency rates reveal that the non-Hispanic White patient was twice as likely as the Hispanic patient to receive a recommendation for antidepressants . A study examining prescription patterns for adults with depression similarly found higher rates of anti-depressant medication for NHW's but the comparison group was African Americans as opposed to Hispanics [21]. The finding is also indirectly consistent with results of other studies that have demonstrated that Non-Hispanic Whites are more likely to be diagnosed with mood disorders [17]. --- Strengths and Limitations Strengths of this study include the collaborative researchpractice partnership team that worked together to develop the study aims and methods. The clinical vignette stimuli that was developed served the study design well in most regards in that the key outcomes for diagnostic decision-making and psychopharmacological treatment yielded sufficient variability to test for group differences . The standardization across race/ethnic groups was evaluated to be successful with equivalent ratings on constructs such as "attractiveness" and "believability." Ironically, it is possible that the lack of race/ethnic effects in this study may also reflect the care given to making sure the vignettes were equivalent in every respect except for the race/ethnicity of the mother. In other words, constructs that could be indirectly associated with race/ethnicity of the family were explicitly controlled, such as health insurance coverage, treatment motivation, prior treatment history, and parental education level. However, given that the goal was to test an isolated effect of patient race/ethnicity, this equivalence was essential to the study design. Of course, as noted in the introduction, one of the limitations of any study utilizing mock patient stimuli is that responses may not generalize to actual physician practice. We attempted to mitigate this limitation by working with a group of practicing physicians to refine the clinical vignette for maximum "ecological validity," . Professional actresses were employed to deliver the vignette and their "believability" was rated very high. This study is the only one we are aware of that actually examines the potential role of physician decision-making in race/ethnic disparities of service use in children's mental health care. Most studies examine service use patterns and thus cannot parcel out the role of physician treatment recommendations. Even studies of medication use have relied on prescriptions filled to identify disparities [21]; rates of prescriptions filled do not necessarily reflect provider practice. One of the major significant limitations of the study is the disappointingly low response rate. This is often a challenge in broad survey research lacking significant funding for respondent compensation. As noted earlier, one of the challenges of this web-based survey format with embedded video stimuli was that the speed of accessing the video and the survey options varied depending on internet access and device used. Some potential participants did not complete the survey due to delays in accessing the video. The final sample of 371 physician participants with complete data was diverse in terms of gender, age, race, etc. Physicians from 44 states and many different types of practices are included and the distribution across the targeted specialties most likely to treat these types of patients was relatively equivalent. --- Conclusion This study did not provide compelling evidence of an isolated effect of patient race/ethnicity on physician diagnostic or treatment decision-making for children with disruptive behavior problems and their families. There was only one significant finding demonstrating an effect of patient race/ethnicity on recommendation for antidepressant medication, with the non-Hispanic White patient being twice as likely to receive this recommendation compared to the Hispanic patient. Given the well-established race/ethnic disparities in psychoactive medication use, more research is needed to identify factors at all levels of analysis that may be driving these disparities. --- Addendum: Vignette Script David's 3rd grade teacher told me to bring him to your clinic for an evaluation. He's been getting into a lot of serious trouble at school-and at home too. He seems angry all the time and he's been really aggressive. He was suspended from school last week for throwing a chair at the teacher-I couldn't believe he did that. I keep getting calls at work because he's been sent to the Principal's office at least five times in the past couple months-all for some kind of acting out. They tell me he often argues with the teacher and refuses to obey her-I believe it, because he's been like that at home too. He's got a quick temper and he gets too rough with his 2-year-old brother. I'm really worried that he's going to hurt him. He teases him all the time and blames him for all his own mistakes, like when he breaks something. It's really difficult to get him to help out at home-He talks back and I have to keep reminding him over and over again. He's very forgetful and distracted. If I try to correct him for something, he gets really "touchy"-He over-reacts to anything he thinks is criticism. We live with my parents now since my husband and I split up a few years ago. My mom has been really concerned about David too and she went to a parenting class with me a few months ago. We tried some of the strategies, but it hasn't really helped. When I look back, it's clear that David's been a slightly challenging kid since day 1, but he is smart and his grades were OK until recently. Of course, since kindergarten, his teachers have mentioned that he gets distracted easily, and he got inpatient, but nothing like he is now. This year his grades have gone way down and he often doesn't even do his work. I'm really worried because the teacher said he may not be able to stay at his school. You know, he's always been a healthy, active kid, but now he's stopped playing baseball and he really doesn't do anything with friends. I'm at my wit's end with this kid. I am willing to try anything and my health insurance will cover whatever treatment you suggest. Thank you. --- Conflict of Interest Statement Author Garland, Author Taylor, Author Brookman-Frazee, Author Baker-Ericzen, Author Haine-Schlagel, Author Liu, and Author Wong declare that they have no conflict of interest. Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2000 . Informed consent was obtained from participants for being included in the study.

Race/ethnic disparities in utilization of children's mental health care have been well documented and are particularly concerning given the long-term risks of untreated mental health problems (Institute of Medicine, 2003; Kessler et al. Am J Psychiatry 152:10026-1032, 1995). Research investigating the higher rates of unmet need among race/ethnic minority youths has focused primarily on policy, fiscal, and individual child or family factors that can influence service access and use. Alternatively, this study examines provider behavior as a potential influence on race/ethnic disparities in mental health care. The goal of the study was to examine whether patient (family) race/ethnicity influences physician diagnostic and treatment decision-making for childhood disruptive behavior problems. The study utilized an internet-based video vignette with corresponding survey of 371 randomly selected physicians from across the USA representing specialties likely to treat these patients (pediatricians, family physicians, general and child psychiatrists). Participants viewed a video vignette in which only race/ethnicity of the mother randomly varied (non-Hispanic White, Hispanic, and African American) and then responded to questions about diagnosis and recommended treatments. Physicians assigned diagnoses such as oppositional defiant disorder (48 %) and attention deficit disorder (63 %) to the child, but there were no differences in diagnosis based on race/ethnicity. The majority of respondents recommended psychosocial treatment (98 %) and/or psychoactive medication treatment (60 %), but there were no significant differences based on race/ethnicity. Thus, in this study using mock patient stimuli and controlling for other factors, such as insurance coverage, we did not find major differences in physician diagnostic or treatment decision-making based on patient race/ethnicity.

Introduction This paper deals with the direct impacts of extreme climatological, hydrological, and meteorological events, and their associated hazards and disasters on human wellbeing, and the life-supporting systems related to environmental health in mainland Latin American countries. The vulnerability issues that are related to human wellbeing, environmental health, and Climate-Sensitive Disasters are emphasized. The impacts resulting from sudden shock extreme climate and weather events and Climate-sensitive Disasters on human wellbeing and health are an area which is getting increased attention because the slow-onset changing patterns of climate will bring more frequent and severe EWEs, leading to more burden of disease [1][2][3][4][5]. The increasing evidence of the links between extreme El Niño events and global warming suggest that the occurrence of such uneven EWEs and their associated climate hazards could increase in the future due to climate change [6], which, in turn, is likely to trigger disasters and health vulnerability to climate [7][8][9]. Due to EWEs can be harmful to humans and their life-supporting systems, and even cause loss of lives, managing their risks and disasters is, therefore, crucial when considering its interlinkages with human wellbeing and health [1][2][3]7,[9][10][11]. Health is not only an indispensable right but a condition that enables the full enjoyment of other rights. The 2030 Agenda for Sustainable Development and goals reflects this view by proposing a universal, integrated, and indivisible vision that clearly expresses the interlinked nature of human wellbeing and health with economic and environmental sustainability [12]. However, climate change is expected to cause approximately 250,000 additional deaths globally per year from malnutrition, malaria, diarrhoea, and heat stress between 2030 and 2050 [10]. Therefore, in the future, a decrease in public spending on health and social care may aggravate inequality of health outcomes that are related to climate change [12], which in turn will make the region into the most vulnerable area for health [13]. Efforts towards a better understanding of such human impacts have progressed and expanded considerably in the last few years [14,15]. Climate change affects human wellbeing and health in many direct and indirect ways [16,17]. These impacts are primary , secondary, and tertiary . Here, the focus is on the primary impacts and trauma from CSDs [18,19]. --- Impacts of Climate Change and Extreme Weather Events on Human Wellbeing in Latin America The rather low level of human and socio-economic development of most countries in Latin America makes it one of the most vulnerable regions in the world, as far as the impacts of climate change, EWEs, and CSDs are concerned [19][20][21]. Some of the effects of climate change influencing health in LA are the increased frequency of EWEs; worsened ambient air quality; altered distribution of allergens; and a modified distribution of vector-borne infectious diseases [3,6,10,12,15,19]. Also, the adaptive capacity of the human systems in LA is low when compared with the industrialized countries, particularly against EWEs, and their vulnerability is high [19]. People living in poor households and/or exposed to climate hazards, for example, are particularly vulnerable to the resulting health risks and are exposed longer to the health consequences from slow-onset climate change problems, and particularly, sudden EWEs , and their related CSDs [12,[17][18][19]. For instance, from 2000 to 2015 the disasters in South America have increased significantly affecting almost 74 million people [21]. The most common disasters have been floods , followed by storms , landslides , and extreme temperatures [22]. This recent worsening of trends has been leading to changes in human mobility, as people tend to abandon some areas due to unfavourable environmental conditions [20,22]. Future climate projections suggest increases in temperature and changes in precipitation for Central America and South America by 2100 [21]. LA countries, which contribute little to climate change but are hard-hit by extreme weather events [3,19,23], urgently need new indicators of vulnerability and exposure to EWEs to back up their claims for financial and technical assistance [23]. 1.2. Defining Key Concepts: Human Wellbeing, Health Vulnerability to Climate, Environmental Health and Climate Change Adaptation The following interrelated and complementary definitions focus on the research framework of this article. Human wellbeing is a holistic construct that goes well beyond the dimensions of biophysical health services, e.g., clean air, a safe and adequate water supply, and a global ecosystem that will continue to provide these services at an individual level. Its meaning is captured in the World Health Organization's definition of health "a state of complete physical, mental and social wellbeing and not merely the absence of disease and infirmity" [24]. These biophysical health services are closely related to the life-supporting systems concept used by the Notre Dame Gain Index [25], as well as to environmental wellbeing. The vulnerability is composed of three elements: Exposure-E, Sensitivity-S, and Adaptive Capacity-AC [4]. Human health vulnerability to climate is a function of: Sensitivity: the extent to which health , are sensitive to changes in weather and climate and the characteristics of the population; the exposure to the climate-related hazard ; and the adaptation actions that are in place to reduce the burden of a specific adverse health outcome , the effectiveness of which may influence the exposure-response relationship [26]. Vulnerability measures a country's exposure, sensitivity, and ability to adapt to the negative impact of climate change in life-supporting services, where E is the nature and degree to which a system is exposed to significant climate change, independent of socioeconomic context, sensitivity is the extent to which a country is dependent upon a sector negatively affected by climate hazards, or the proportion of the population that is particularly susceptible to climate change hazards, and AC is the availability of social resources for sector-specific adaptation capacities. The ND-Gain health score captures a country's of public health vulnerability to climate change, regarding the spread of communicable diseases and provision of health services [25]. Environmental health is the science and practice of preventing human injury and illness and promoting wellbeing by identifying and evaluating environmental sources and hazardous agents and limiting exposures to hazardous physical, chemical, and biological agents in air, water, soil, food, and other environmental media or settings that may adversely affect human health [27]. Climate Change Adaptation refers to "the process of adjustment to actual or expected climate and its effects" [4]. --- Research Framework There are unfortunately few international studies that address the climate disasters-human wellbeing-sustainable development nexus in the Latin American context. This article aimed to make a cross-comparison survey that looked at a set of seventeen mainland countries from Central , Mexico , and South America about the health vulnerability and direct impacts on human wellbeing that are associated with and , based upon the disaster country-level statistics from 1997 to 2016, see Section 2). Additionally, an online survey with regional environmental and climate researchers supports the disaster statistics. The study emphasizes primary human impacts and stress of EWEs, namely total death and affected people. The working hypothesis is, as modified from Leal Filho et al. [17]: "All countries and regions worldwide show some degree of vulnerability, are exposed and are directly or indirectly impacted by climate-related hazards regardless of their socioeconomic status and readiness". The research problem is related to the following question based on the working hypothesis: "Are the direct human impacts of CSDs primarily due to their frequency and intensity, or to the intrinsic human and socio-economic determinants of wellbeing and health inequalities?" Therefore, the objectives of this paper are to respond to these questions. For doing so, an update of relevant indices that are related to the human vulnerability to climate and the impacts of extreme climate/weather events on human wellbeing from 1988 to 2017 is carried out. Some suggestions, which are based on these results, the literature, and an online survey, are made, about how LA countries could improve climate change adaptation of the public health sector to CSDs and their link with disaster risk reduction . The basic concepts, terms, and assumptions of the analytical framework that is used to construct causal explanations [28] of the Drivers-Vulnerability-Actions interactions causing the observed Climate-Sensitive Disasters and their impacts on human wellbeing to be as follows : External climate drivers are uncontrollable on the short-and medium-term at the local level, whereas socioeconomic driving determinants are to be uncontrollable on the short-term, but potentially modifiable [17]; The drivers of this system are external: climate change and extreme weather events , and socio-economic determinants of public health ; internal: knowledge and values; human safety, public health infrastructure, and investment ; The vulnerability is composed by the exposure [1,25], assumed as being uncontrollable on the short-to medium-term, the sensitivity , and the adaptability composed of the adaptive capacity and readiness [25]. The components ii and iii are moderately modifiable on the medium-term; The actions relate to the country-level decision-making level that are both influenced by and influence the concepts and terms mentioned above. Measures that are not primarily intended to reduce the current climate vulnerability and socioeconomic determinants are close to disaster preparedness and response, such as weather forecasting, early warning systems, evacuation, and relief . All of these elements overlap within a continuum interacting system. For instance, readiness, preparedness, and response are closely inter-related. The former is Climate Change Adaptation and the latter is Disaster Risk Reduction , which, ideally, should be regarded as inter-linked [5]. Some of the principal expected outputs of this research are as follows: extreme weather events directly affect the human wellbeing of vulnerable people, particularly among the poor and those more exposed people, and influence public health policies; wellbeing and health impacts of extreme weather events are linked to the human and socioeconomic development determinants of the health inequality, and the expenditures in Public Health; and, building resilience to extreme weather events and policies to support it, linked with disaster risk reduction actions are needed. --- Figure 1. Drivers-Vulnerability-Actions interactions schematic . --- Materials and Methods The methodology of this study consisted of four steps: Step 1: Identification of the sample of countries and compilation of a list of climate-stressors, geographical, human, and socioeconomic determinants of the health vulnerability and safety issues, extreme weather events , and Climate-Sensitive Disasters in the studied countries; Step 2: Collection of evidence-based statistics of EWEs and CSDs from 1988 to 2017 and their direct human impacts from the public available source EM-DAT CRED database [29] and the Global Climate-Risk Index-CRI from 1997 to 2016 [30]; Step 3: Collection of opinions from a sample of LA climate and environmental researchers and practitioners about climate change, EWEs, health vulnerability to climate, and the main perceived barriers and possible solutions in LA; and, Step 4: A comparative qualitative and quantitative analysis of the geographic and socioeconomic determinants of the vulnerability in regards to EWEs, CSDs, and wellbeing and environmental health. The study addresses the following methodological processes: --- Identification of the Sample of Countries and Compilation of the Primary Determinants of Health Vulnerability to Climate and Adaptation to Extreme Weather Events The collection of the vulnerability, risk, and adaptation issues was made from the sample of seventeen mainland countries of Latin America, as follows: South America , Central America , and Mexico . The LA Caribbean islands will be subject to another study by the International Climate Change Information Programme . The vulnerability is different from risk. Whereas, risk is about exposure to external hazards over which people have limited control, vulnerability is a measure of people's capacity to manage such hazards-to prepare for, cope with, and recover from them without long-term, potentially irreversible losses of wellbeing [31]. Geographical factors, such as land area and populations, serve to assess the impacts normalised by the Population Density. Decreasing/increasing values order human and socioeconomic indicators expressed as per capita or percentage , absolute figures, and discrete classes . The indices used are: the Notre Dame University Gain Index [25]; the German Watch Global Climate-Risk Index [27]; the United Nations Human Development Index [32]; and, [1,4,17,25,26]). --- Materials and Methods The methodology of this study consisted of four steps: Step 1: Identification of the sample of countries and compilation of a list of climate-stressors, geographical, human, and socioeconomic determinants of the health vulnerability and safety issues, extreme weather events , and Climate-Sensitive Disasters in the studied countries; Step 2: Collection of evidence-based statistics of EWEs and CSDs from 1988 to 2017 and their direct human impacts from the public available source EM-DAT CRED database [29] and the Global Climate-Risk Index-CRI from 1997 to 2016 [30]; Step 3: Collection of opinions from a sample of LA climate and environmental researchers and practitioners about climate change, EWEs, health vulnerability to climate, and the main perceived barriers and possible solutions in LA; and, Step 4: A comparative qualitative and quantitative analysis of the geographic and socioeconomic determinants of the vulnerability in regards to EWEs, CSDs, and wellbeing and environmental health. The study addresses the following methodological processes: --- Identification of the Sample of Countries and Compilation of the Primary Determinants of Health Vulnerability to Climate and Adaptation to Extreme Weather Events The collection of the vulnerability, risk, and adaptation issues was made from the sample of seventeen mainland countries of Latin America, as follows: South America , Central America , and Mexico . The LA Caribbean islands will be subject to another study by the International Climate Change Information Programme . The vulnerability is different from risk. Whereas, risk is about exposure to external hazards over which people have limited control, vulnerability is a measure of people's capacity to manage such hazards-to prepare for, cope with, and recover from them without long-term, potentially irreversible losses of wellbeing [31]. Geographical factors, such as land area and populations, serve to assess the impacts normalised by the Population Density. Decreasing/increasing values order human and socioeconomic indicators expressed as per capita or percentage , absolute figures, and discrete classes . The indices used are: the Notre Dame University Gain Index [25]; the German Watch Global Climate-Risk Index [27]; the United Nations Human Development Index [32]; and, the Legatum Prosperity Index for Health [33]. The ND-GAIN Country Index summarises a country's vulnerability to climate change and other global challenges in combination with its readiness to improve resilience. The ND-VR measures vulnerability and readiness when it comes to climate change and weather-related hazards impacts .The specific analyzed sectors that are related to the health vulnerability to climate are Public health : The spread of communicable diseases and provision of health services; water : Freshwater supplies and access to reliable drinking water; and Human habitat : Human living conditions, while considering weather extremes. Exposure relates here to the geographical location and the occurrence of climate changes and hazards . This definition of exposure is very similar to the one that is given for risk. Generally, a composite index is developed to either measure a multidimensional concept or to describe a system. In cases where the goal is to measure a multifaceted concept, an aggregation of a parsimonious set of indicators can be effective [34]. Here, the additive unweighted ND-Gain sectoral health vulnerability indices [∑V = PHV + WV + HHV], exposure and sensitivity [E + S], and Adaptability indices Adaptive Capacity and Readiness [AC + R] were classed by the authors based on their distribution in the ND-VR ranked tables so as 1, 2 . . . , 5 represent the quintiles of the distribution. There can be no claim that this additive aggregation is an index, but a way to rank and compare countries by a set of indicators. Then a relative rank was made for these two blocks of aggregated indicators . The HDI, for example, organizes indicators into three main dimensions of human wellbeing: health, education, and income [32]. These socio-economic and human development indicators are the per capita parity purchase power Gross domestic product ; Education level of the population; and Life Expectancy . This index is classed as very low, low, medium, high, and very high [32]. HDI is a standard index in studies on the nexus climate adaptation, extreme weather events, sustainable development, and DRR [17,[35][36][37][38]. The CRI analyses to what extent countries have been affected by the impacts of weather-related events from 1997 to 2016 [27]. The Legatum Prosperity Index offers a unique insight into how prosperity is forming and changing the world. The LPI ranking is composed of nine equally-weighted sub-indices, one of which is health . This sub-index measures a country's performance in basic health, health infrastructure, and preventative care indicators [33]. The Per capita Gross National Income GNI = [39]. Poverty expressed as the percentage of the population [40] is a direct indicator of human and socioeconomic status, health inequality, and an indirect sign of social vulnerability against climate hazards. Poverty and vulnerability are interrelated as they influence each other and as very often poor people are the most vulnerable to any adverse effects of any risk [41]. --- Extreme Climate and Weather Events and Climate-Sensitive Disaster Statistics in the Seventeen Studied LA Countries An analysis of climatological, hydrological, and meteorological disasters was carried out based on the annual country-level statistics from 1988 to 2017 for floods, drought, storms, landslides, and wildfires from the EM-DAT CRED database [29]. The accumulated occurrence of all disasters was 1096 . EM-DAT continuously updates the country-level Top Ten disasters , which are also presented . --- A Survey on Perceptions of the Health Impacts of Extreme Weather Events and Sea Level Rise in Latin America Bearing in mind the limitations and constraints seen in data collection as part of international studies, the method that is chosen to complement the selected indices and statistics at the national level, was an online survey, deployed to gather information from a variety of Latin American researchers and stakeholders. The online survey was disseminated via email from November to December 2017 while using Google Forms. The sample was based on those who took part in the survey out of their own will. Consistent with good academic practice and based on the need to adhere to data protection procedures, the study was anonymous. The survey instrument was composed of 14 questions that aimed to characterize the perceptions on climate change, risk, and extreme events impacts, on human wellbeing and health in mainland LA countries. The Supplementary Information includes a copy of the online survey . A total of 52 responses were received, checked, and analyzed for percentages and frequencies on the closed questions data collected, and content of open items, and subsequently quantified as percentages. The survey had the following limitations: Firstly, a relatively small sample when compared to other studies, partly because the study was performed with no external support. Secondly, there is some geographical imbalance in the answers to the survey . Thirdly, the time scale of only one month. Because of these limitations, the reliability of the data is limited and it is not statistically representative of independent research. However, since scientists that were working on climate-related human impacts research provided the questions, and respondents volunteered to submit their contributions since the processing of the data was transparent and since the discussion of the manuscript acknowledges and keeps in mind the limitations of the survey, it is only an additional input that is used to support the debate. Therefore, the data collected allow for only a rough profile of the current public perception of the extreme events, preparedness, and barriers to adaptation, and a few suggestions to reduce vulnerabilities. --- Comparative Analysis of the Determinants of EWEs, CSDs, and Environmental Health To describe the qualitative and some quantitative relationships between the climate-risk, and human and socio-economic indices of development, vulnerability, and adaptation, the indicators and indices were not weighted. However, per capita GDP appears in more than one aggregated index , which indirectly enhances its weight. Regression and correlation analysis were performed between the climate-risk, geographical, human, socio-economic, and health vulnerability/adaptation indicators/indices with the figures of impacts due to CSDs, and the most relevant and significant ones were retained. All data were ordered and ranked. The ND-Gain vulnerability and adaptability indicators were discretised in five classes or quintiles from the original data. The indices that are used for comparative analysis are the HDI; Poverty ; GNI, LPHI; Fatalities from the CRI, and the aggregated blocks of vulnerability sectors that are related to human wellbeing , plus exposure , Sensitivity , and adaptability . All of these were ranked , and some were classed to illustrate semi-quantitative relationships . --- Results This section is divided into four subsections, as follows. --- Geographical, Socio-Economic and Vulnerability Setting This section presents country-level indicators and indices of human and socio-economic determinants of health vulnerability to climate, risks, adaptation, and direct impacts on human wellbeing due to extreme weather events and climate-sensitive disasters from EM-DAT and CRI databases. Some quantitative relationships between indices and human impacts were carried out. This subsection is divided as follows. --- The Geographical and Climatic Setting of Extreme Weather Events Tables 1-3 summarise the land area and populations [42], the prevailing Köppen classification climate-types [43], and the main weather extreme events [27] of the studied countries. The prevailing Köppen climate-types are the following: Tropical , which prevails in Brazil, Colombia, Ecuador, Venezuela, and CA; Temperate , which prevails in Argentina, Chile, Paraguay, Peru, and Uruguay, and semi-arid , which prevails in Bolivia and Mexico. The most common subtypes are Tropical Wet-AW , mostly in CA, northern SA countries, and Brazil, and Temperate Oceanic-Cfb , in the coast of Peru as well as in most coastal states in SA and CA. The prevailing EWEs are Riverine floods , storms , and droughts . Extreme temperatures are typical in at least seven countries. In Table 3, the GDP Per Capita , and the public and private expenditures in Health are presented based on data from the Pan American Health Organization-PAHO/WHO [18]. The authors calculated regional ranks and per capita expenditures from these data. This section describes the descriptors of the fatalities due to EWEs in the studied LA countries from the datasets that are provided by the CRI statistics , ND-Gain LPHI Indices, and EM-DAT statistics . Geographical Exposure was determined based on the population density through normalisation per population and area, and classed as 1: very low and 5 very high, where the lowest the best . Table 4 summarises the data used for the analysis, including the GNI, HDI, and LPHI indices. --- A Few Selected Quantitative Relationships between Indices and EWEs Figure 2 shows the relationship between the HDI 2016 and the number of fatalities per Million inhabitants in the studied countries . Nicaragua, Honduras, and Paraguay deviate from the linear function HDI-Fat . The eight countries with HDI ≥ 0.75 have fatalities ≤3 per M inh., as well as Paraguay, which shows fewer impacts than expected from their development status. If the ranked LPHI 2017 is used as an independent variable against the ranked fatalities , a positive linear relationship is found with Argentina, Brazil, and Venezuela performing better than expected, and El Salvador and Honduras performing worse than expected from this LPHI descriptor. The relationship poverty rate vs. fatalities per M inh. is linear with Nicaragua as an outlier. Figure 2 shows the relationship between the HDI 2016 and the number of fatalities per Million inhabitants in the studied countries . Nicaragua, Honduras, and Paraguay deviate from the linear function HDI-Fat . The eight countries with HDI ≥ 0.75 have fatalities ≤3 per M inh., as well as Paraguay, which shows fewer impacts than expected from their development status. Climate-Risk Index Report [30]. If the ranked LPHI 2017 is used as an independent variable against the ranked fatalities , a positive linear relationship is found with Argentina, Brazil, and Venezuela performing better than expected, and El Salvador and Honduras performing worse than expected from this LPHI descriptor. The relationship poverty rate vs. fatalities per M inh. is linear with Nicaragua as an outlier. Climate-Risk Index Report [30]. If the ranked LPHI 2017 is used as an independent variable against the ranked fatalities , a positive linear relationship is found with Argentina, Brazil, and Venezuela performing better than expected, and El Salvador and Honduras performing worse than expected from this LPHI descriptor. The relationship poverty rate vs. fatalities per M inh. is linear with Nicaragua as an outlier. The population density shows a moderate correlation with fatalities per M. people for 15 countries ; the states with the highest value are El Salvador and Guatemala. The recent trend of occurrence of EWEs is increasing in at least five countries , whereas it decreased in Honduras . The population density shows a moderate correlation with fatalities per M. people for 15 countries ; the states with the highest value are El Salvador and Guatemala. The recent trend of occurrence of EWEs is increasing in at least five countries , whereas it decreased in Honduras . Table 5 shows the country-level top-ten natural disasters, the number and type of climate/weather ones among them, and the Total Affected Population . The countries with the highest percentage of TAP due to natural disasters are Honduras, Nicaragua, Peru, Costa Rica, Bolivia, and Brazil , while those with the lowest percentage are Venezuela, Ecuador, Chile, Uruguay, and Mexico . In most countries EWEs prevail among the top-ten natural disasters, reaching 10/10 in Argentina, Bolivia, Honduras, Mexico, Paraguay, and Uruguay. Table 5 shows the country-level top-ten natural disasters, the number and type of climate/weather ones among them, and the Total Affected Population . The countries with the highest percentage of TAP due to natural disasters are Honduras, Nicaragua, Peru, Costa Rica, Bolivia, and Brazil , while those with the lowest percentage are Venezuela, Ecuador, Chile, Uruguay, and Mexico . In most countries EWEs prevail among the top-ten natural disasters, reaching 10/10 in Argentina, Bolivia, Honduras, Mexico, Paraguay, and Uruguay. The classed aggregated ranked vulnerability-CRV , is linearly related with the adaptability , which shows a good fit with the country-level ranked fatalities . Given that CRA was not tested , this relationship is only used to illustrate the importance of readiness and adaptation. The classed aggregated ranked vulnerability-CRV , is linearly related with the adaptability , which shows a good fit with the country-level ranked fatalities . Given that CRA was not tested , this relationship is only used to illustrate the importance of readiness and adaptation. Focusing on the relationships between the chosen descriptors and those that show better/worse performance than expected from the descriptor and the outliers , some patterns emerge from Figures 2345and Tables 1-5: • there is a negative and significant relationship between HDI and the number of fatalities, including the outliers ; • Paraguay performs better than expected from HDI and in line with its good LPHI , while Argentina, Brazil, and Mexico perform better than expected regarding their Focusing on the relationships between the chosen descriptors and those that show better/worse performance than expected from the descriptor and the outliers , some patterns emerge from Figures 2345and Tables 12345• there is a negative and significant relationship between HDI and the number of fatalities, including the outliers ; • Paraguay performs better than expected from HDI and in line with its good LPHI , while Argentina, Brazil, and Mexico perform better than expected regarding their HDI, and Brazil and Argentina do the same regarding their LPHI; • there is a positive and significant linear trend between poverty and fatalities per M inh. . Argentina, Paraguay, and Guatemala perform better than expected from this trend; • the high and very high poverty percentages of Nicaragua , El Salvador , Bolivia , Guatemala , and Honduras are quite well correlated with fatalities, while Argentina and Paraguay perform better than expected from the trend, which is in line with their LPHI. Guatemala's fatalities lie below expected from HDI, poverty, and LPHI; • the HDI index, the poverty rate , and the classed LPHI and CRV are quite well related to the fatalities per M inh. , except for outliers Honduras and Nicaragua, which show terrible socio-economic and vulnerability indicators. There are a few examples of countries performing somewhat better than expected from the chosen descriptors ; and, • the aggregated discrete adaptability shows a good fit with the ranked fatalities . The same, but less clear was for CRV . --- Online Survey: Perceptions of the impacts of Climatic Changes and Extreme Weather Events on Human Wellbeing and Health in LA Countries, and Possible Solutions An online survey on the perceptions of the impacts of Climate Changes and EWEs on human wellbeing and health in LA countries and possible solutions is presented to support the CSD statistics, and to further discuss its linking with data. The number of respondents to the questionnaire was 52, most of them from the academia , 75% of which came from Argentina, Brazil, Mexico, Paraguay, Uruguay, and Venezuela; although the survey data is small, it contributes somehow to respond to the research problem. The Most common extreme events that were identified by the respondents were as follows : inundation and river floods ; storms ; droughts ; fires ; heat waves ; and, others . Two selected excerpts from the participants are. "The preliminary draft of the Framework Law on Climate Change, drafted for just over a year, is in the process of socialisation, seeking to put Paraguay among the first countries to address this problem at the global level". "The XXI century needs the integration of self-care, care for the other, and care for the whole planetary ecosystem. There is a need for a new ethos in our health professions; we need to transform our paradigms of health". --- Linking Data to Perceptions Here, the results presented in Section 3.1 and the perceptions introduced in Section 3.2 are compared. Most common extreme events that were identified by the respondents to their country are in line with data presented in Section 1.1: Floods , storms , landslides , and extreme temperatures , and Tables 1, 3 and 4: Floods followed by storms and droughts . When the topic is climate change information the references to the media are immediate and when asked "what could be done" respondents also mention "Information and Media". Preparedness in the region is negatively perceived and concomitantly when asked "what could be done" respondents prioritise "Information systems in a changing climate, Early Warning Systems, Risk Assessment, management and communication, preparedness". The above statements also highlight the importance of extreme events in a context of high vulnerability and geographical exposure . There is an observed high level of awareness of the links between climate change and human wellbeing and health. Climate change, environmental health, health inequalities, assumes greater importance in regions where poverty poses a challenge to social justice, environmental justice, and sustainability . When asked "what could be done" respondents prioritise "Health capacities, Promoting Health, epidemiology of the identified priority vector-borne zoonotic diseases" but also "Capacity Building and Partnerships", and also mention "Participation, empowering stakeholders to build partnerships, participate in building resilience in a changing climate". --- Classed Ranked Vulnerability and Adaptability, and Climate-Risk Based on the classed ranked vulnerability and adaptability and the Total Affected People due to Top-ten EWEs , the authors have compared the countries' relative risk from very low to very high to Climate-sensitive Disasters. For instance, the extremes include Honduras and Nicaragua and Argentina and Chile . --- Discussion This article discusses the occurrence and direct human wellbeing impacts of climate variability and extreme events in mainland Latin American countries that were centred over the period 1988-2017. The principal assumptions are as follows: an increase in the frequency and/or magnitude of Extreme Weather Events [1][2][3][4][5][6]12,[19][20][21][22][23]; all countries show some degree of vulnerability, are exposed, and are impacted by EWEs, regardless of their socio-economic status and readiness [17]; and the geographical and climatic settings are mostly uncontrollable, while the socioeconomic determinants of health vulnerability to climate are assumed modifiable in the medium-term. --- The Assessment of the Determinants of Vulnerability and Impacts The assessment builds on the geographical and socio-economic determinants of health --- Discussion This article discusses the occurrence and direct human wellbeing impacts of climate variability and extreme events in mainland Latin American countries that were centred over the period 1988-2017. The principal assumptions are as follows: an increase in the frequency and/or magnitude of Extreme Weather Events [1][2][3][4][5][6]12,[19][20][21][22][23]; all countries show some degree of vulnerability, are exposed, and are impacted by EWEs, regardless of their socio-economic status and readiness [17]; and the geographical and climatic settings are mostly uncontrollable, while the socioeconomic determinants of health vulnerability to climate are assumed modifiable in the medium-term. --- The Assessment of the Determinants of Vulnerability and Impacts The assessment builds on the geographical and socio-economic determinants of health vulnerability to climate and human wellbeing impacts from several indices, and the International Disaster Databases EM-DAT and Global Climate Risk Index-CRI . Over the studied period , the most conspicuous EWEs have been riverine floods, storms, and droughts, followed by extreme temperatures, wildfires, and landslides, which agrees with other previous studies [19,23,44]. The following socio-economic determinants of health are relevant in this discussion: Inequity "A disparity in health outcomes that is systematic, avoidable, and unjust" [45]; Inequality "Differences, variations, and disparities in the health achievements of individuals and groups of people" [46]; Disparity "A type of difference in health that is closely linked with a social or economic disadvantage that negatively affects groups of people who have systematically experienced greater socioeconomic obstacles to health " [47]. These concepts relate to the determinants of health [48] that determine the impossibility to afford basic needs for human wellbeing, such as clean water, nutrition, healthcare, education, clothing, and shelter. Climate events worsen health disparities in developing countries as a whole and weather extremes in particular. As a result, environmental health problems that are associated with the indirect climate impacts [16], such as stress due, for instance, to damages to crops and properties, thermal discomfort [49], or increases in the transmission of mosquito-borne diseases [50] tend to widen the gap and make populations in developing countries even more vulnerable than they already are. Equality stands at the centre of development; the gaps in the provision of services are associated with the persistence of slums, whose inhabitants frequently face higher risks of exposure to communicable diseases, environmental pollution, and natural disasters [51]. The disparities in the wellbeing and health geographical, climatic and socioeconomic determinants presented in Tables 1-5 are mutually-aiding with the CSD-related human impacts. They provide qualitative and quantitative insight to answer the research question "Are the direct human impacts of CSDs primarily due to their frequency and intensity or to intrinsic human and socio-economic determinants of wellbeing and health inequalities?". The geographical and climatic determinants are a significant and fundamentally uncontrollable factor of country-level health vulnerability to climate. For instance, most storm-prone countries have a tropical climate, mainly in CA; and most riverine flood-countries are temperate, subtropical SA countries. The smallest and highly populated CA countries, notably El Salvador, Honduras, and Nicaragua, show high human impacts beyond other main determinants. The development status, vulnerability, adaptation and climate-risk indices , and health expenditures show strong country-level disparities. For instance, poverty levels vary from only 9-11% to 59%-66% , and the Climate Risk Index and fatalities values range from very low or low to very high ones . The aggregated indices HDI and LPHI are quite well correlated with the number of fatalities per million inhabitants, while poverty level, a proxy of social vulnerability [41], is likely a key determinant , without overlooking the exposure to and the magnitude of EWEs. The Classed Ranked Adaptability aggregated by the authors from the ND-Gain indices is inversely related to the country-level ranked fatalities , highlighting the importance of the human, socioeconomic and political willingness determinants of the capacities to implement adaptation measures and the ability to leverage investments and convert them into adaptation actions . For instance, the Total Health Expenditures vary from 4.8% to 9.8% and from US$ 175 in Nicaragua to US$ 1352 in Uruguay . The ranked fatalities per M inh. are well correlated with the ranked HE in most countries . The lousy performance of Guatemala coincides with the worst social determinants, e.g., the very low public HE and GDP , high poverty , besides high population density and climate-risk index. Are the relative high expenditures in the health of Paraguay a cause of the below-expected fatalities in this country? The excerpts taken from the online survey suggest the existence of a high level of awareness, which could be a consequence of the relatively high percentage of people affected by CSDs , which is mainly due to extreme floods [52,53]. The Total Affected People indicator shows a high diversity with countries with very low TAP due to CSDs to very high figures . The exposure of small storm-prone CA countries could be explained by their high population density, prevailing climate, and disaster profile, besides low to very low adaptability and health expenditure indices. On the other hand, the case of Uruguay is particularly interesting because it is a flood-prone country and it suffers frequent extreme windstorms. Its relatively low vulnerability may be attributed to its good Adaptability, as shown in Table 3, and to repeated evacuations of the same people along the flood-prone Uruguay River [53]. An example of a successfully anticipatory adaptation measure linked with Disaster Risk Reduction is the Early Warning System, and vulnerability, hazard, and risk map for extreme rainfalls and landslides of La Paz City. The integrated climate and weather forecasting and the risk-mapping system were developed after a deadly landslide occurred in February 2002 with a death toll of 63 persons plus 14 missing persons, in addition to the losses and damages to habitat, roads, and water supply and sanitation services. In February 2011 another extreme rainfall occurred, which activated the Early Warning and Risk-mapping System , allowing for prompting the evacuation of inhabitants at risk, which prevented the loss of human life due to the landslide. The first preparedness and response differences with the event of 2002 were: the communication did not fail ; and the existence of an operational EWRMS [54]. Finally, it is worth mentioning in regards to future adaptation that the studied countries, except Brazil, have not implemented National assessment of climate change for health, nor have they taken measures to increase the climate resilience of health infrastructure yet [2]. --- Main Contributions to the Analysis Extracted from the Online Survey The online survey provides several responses regarding EWEs, barriers, policy actions, and approaches to health policy and the Nexus Environment-Human Wellbeing under changing climate-risks. The perception of main EWEs is similar to other studies , and the statistics from 1988 to 2017 presented herein, with floods, storms, and droughts placed as the most frequent and damaging risks. The differences between the perceptions and the reality are attributed to the small sample , and actually most extreme temperatures are cold waves instead of heat waves, which is likely due to more direct impacts of cold. Media Literacy is perceived as a critical strategy for improving climate literacy. Media influence public awareness and opinion on climate change [52,55,56] and shape public understanding of scientific issues being the interface between science production and the lay public knowledge [57,58]. There is a widespread lack of confidence in the available information, preparedness, and actions on EWEs, the health systems and government's DRR measures . However, some respondents have confidence in their national structures which, despite its relatively lousy vulnerability indices, is in line with the Framework Law on Climate Change , the human impacts due to EWEs ; and its relatively good Legatum Prosperity Health Index-LPHI . Several respondents to the online survey believe that policy actions should focus on improving/promoting the health capacities, including research; partnerships and stakeholders' participation; Information systems, climate-risk assessment, and early warning systems; best practices; climate-health nexus research communication at several levels; and climate research. Quite surprisingly, the fundamental causes of poverty and vulnerability were not prioritised, which could be explained by the belief that climate adaptation and disaster risk reduction focus on actions, likely because the causes need strong long-term commitment and investments to be solved. Finally, it is worth mentioning that discourse aligns with new ways to deal with this global climate challenge, namely climate-resilient pathways. Adaptation and sustainable development facing new paradigms to deal with the obstacles CSDs pose to the Health system [50], to global partnerships and promote research [59]. --- Adaptation Strategies to cope with Extreme Weather Events Addressing the causes of vulnerability is a prerequisite for sustainability in managing the Risks of Extreme Events and Disasters to Advance Climate Change Adaptation [3], and with the Sustainable Development Goal 13 , which proposes to strengthen resilience and adaptive capacity to climate-related hazards [18,60]. Therefore, the authors stress the importance of improving the implementation of the following adaptation strategies to building resilience against climate-sensitive disasters in human wellbeing and health. LA countries should develop concerted efforts to identify communities and vulnerable groups whose wellbeing and health is increasingly at risk [13], because healthy, sustainable communities are built on the foundations of both healthy human populations and healthy natural ecosystems [24]. To get this goal some of the needed actions are fostering education coupled with broad public information campaigns for undertaking measures to help to address health and social inequalities resulted from climate-risks [61]; improving healthcare facilities for handling increased patient volume resulting from EWEs [60][61][62]; and, developing National Adaptation Plans-NAPs [2,17,37,38]. An integrated approach to addressing health vulnerability to climate, risk assessment, and climate-disaster preparedness and response [1,5,17,50] should include: joining resource mobilisation for discussing climate-risks and extreme events [5,17]; linking DRR and Climate Change Adaptation for addressing the human health vulnerability to and the risks of CSDs [5,63,64]; and, developing integrated forecasting, early-warning, and climate-related risk-mapping systems of extreme weather events [1,17,37,50,[52][53][54]65] and partnerships among diverse stakeholders [61], e.g., between meteorological and health departments [62] and with partner agencies within the UN system [10]. Structural long-term adaptation strategies should include the increase in public health expenditures [18], universal health coverage, and alleviation of poverty [18,50,66,67]. --- Potential Limitations of the Paper It is inevitable that there are some possible weaknesses because of the underlying assumptions, the selected indices, and relationships that are presented in this paper. Hence, its applicability and the main potential limitations are addressed. Firstly, this paper focused on the direct and short-term human impacts of extreme events and their associated climate-disasters-regardless of climate change but assumed to be triggered by it. However, the indirect effects on the environment wellbeing , are crucial human wellbeing and health factors --- in the medium-term [18,20,24,68]. Similarly, the medium and long-term impacts of droughts , not addressed herein, have been pointed out for the world [1] and Latin America in particular [18][19][20]44]. Secondly, the emphasis is given to total death and affected people, which is not the only human adverse effects, but likely the most important ones. Thirdly, aggregated country-level impacts do not allow for discriminating the many relevant geographical, local, socioeconomic, and gender issues. However, keeping in mind that the poor, elderly, women and children, and those living in vulnerable climatic and geographic sites, are differentially impacted, aggregated studies are useful for cross-comparison research. Despite the above shortcomings, the authors understand the analysis that is presented here is still considered valuable and a base for future more detailed investigation. --- Conclusions Regarding the research problem focused on which are the leading causes of the impacts of extreme weather events on human wellbeing and health impacts in Latin American countries, the presented results suggest that they are mainly related to the socio-economic and human development, the geographic determinants of health vulnerability to climate, and the descriptors of health disparities. Nevertheless, mostly uncontrollable external climate drivers of impacts and exposure are a significant factor in the risk-prone countries. The key findings for the implementation of promising structural adaptation measures and specific actions to reduce the human vulnerability and impacts, are as follows. The countries with the fewer direct impacts on human wellbeing are the ones with the best human, socio-economic, and vulnerability indices, the highest per capita expenditures in Public Health, particularly those with the highest public spending, namely Chile, Uruguay, Costa Rica, Panama, Argentina, Paraguay, Brazil, and Mexico. However, despite the relatively high health investments of highly exposed countries, such as Honduras and Nicaragua, the combination of the frequent occurrence of extreme weather events, high climatic and geographical exposure, and poor development, determine their very high vulnerability and direct human impacts. Various studies have outlined sets of adaptation measures, which may assist countries in Latin America and elsewhere to handle the adverse impacts of climate-sensitive disasters on human wellbeing and health. Based on the results that are presented in this paper and the literature the authors believe that the most cost-effective measures and strategies are the following: The improvement of public awareness, integrated Observational-Forecasting-Modelling-Mapping, and Early Warning System, and the Preparedness and Response infrastructure, logistics, and management . The increase in Health Expenditures focused on the reduction of disparities . The achievement of the Sustainable Development Goals-notably reducing poverty levels . Future research directions should include in-depth analysis of multi-variable quantitative relationships between all of the determinant factors of health vulnerability to climate, and direct and indirect impacts on human wellbeing and their life-supporting systems, as well as further assessments of the barriers, opportunities, and actions that are related to the effective implementation of linked climate adaptation and disaster risk reduction. --- Supplementary Materials: The following is available online at http://www.mdpi.com/1660-4601/15/9/1802/s1, Table S1: Online Survey Responses. Author Contributions: Conceptualization, W.L.F. and G.J.N.; Data curation, U.M.A. and J.H.; Formal analysis, G.J.N., W.L.F. and U.M.A.; Funding acquisition, W.L.F. and G.J.N.; Investigation, G.J.N. and J.H.; Methodology, G.J.N. and W.L.F.; Project administration, W.L.F.; Resources, C.L.; Software, J.H., J.E.V. and C.L.; Supervision,

Climate change and variability are known to have an influence on human wellbeing in a variety of ways. In Latin America, such forces are especially conspicuous, particularly in respect of extreme climatological, hydrological, and weather events (EWEs) and climate-sensitive disasters (CSDs). Consistent with the need to study further such connections, this paper presents an analysis of some of the vulnerabilities of environmental health issues and climate-related impacts that are focusing on EWEs and CSDs in Latin American countries. The research includes an analysis of the (i) human and socio-economic development; (ii) geographical and socio-economic determinants of vulnerability and adaptability of environmental health issues (exposure, sensitivity, and adaptive capacity); (iii) occurrence of CSDs from 1988 to 2017 and their direct impacts on human wellbeing (Total death and Affected people); (iv) an online survey on the perceptions of the effects of EWEs on human wellbeing in a sample of countries in the region; and (v) discussion of possible solutions. The socio-economic and development indices, and the International Disaster Database (EM-DAT) and Climate-Risk Index (CRI) disaster statistics suggest that the impacts of CSDs are primarily related to socio-economic determinants of human wellbeing and health inequalities. Also, >80% respondents to the survey say that the leading causes of climate-related human impacts are the lack of (i) public awareness; (ii) investment and (iii) preparedness. The paper concludes by adding some suggestions that show how countries in Latin America may better cope with the impacts of Climate-sensitive Disasters.

Introduction Women's autonomy -their opportunity to make choices that affect their lives -is an important factor in demographic, economic and health-related outcomes . Studies of women's autonomy related to health care decision-making report definitions and measures of autonomy that encompass similar dimensions: the ability to obtain information and make decisions about one's own concerns, have some control over finances and have some freedom of movement. A woman who can exercise personal autonomy to make decisions is able to improve and maintain her health and seek necessary health-related resources . In studies on reproductive behaviour, women's active participation in decision-making indicates their power within the household. It increases their adoption of modern contraceptives and reduces their desired fertility . The few studies of women's decision-making autonomy in developing countries suggest a close link to women's socio-demographic characteristics and the social settings in which they live. For instance, highly educated women are more likely to be knowledgeable about their own health, have more self-confidence and be more assertive than those with less or no education . These authors concluded that without education and at least a certain amount of wealth, it is difficult for an individual woman to make choices. Age and family structure are strong determinants of women's authority in rural Pakistan -older women and women in nuclear households were more likely to participate in family decisions . The older a woman is, the more likely she is to have negotiating skills and self-confidence leading to decision-making autonomy . According to Nigatu and colleagues , women in south-east Ethiopia with higher household monthly income were more likely to be autonomous. Similarly, poverty, distance to health care services and lack of education exacerbated low levels of women's autonomy in northern Kenya . Women with more children tend to have greater decision-making autonomy . Similarly, employed women are more likely to participate in decision-making than unemployed women . Couples living in urban areas were more likely to jointly make reproductive decisions than rural residents . Being a Muslim woman in Nigeria is associated with lower decision-making power , and religion represents an important aspect of Nigerian family life . Little is known about other socio-demographic characteristics associated with women's autonomous decision-making in Nigeria. Nigeria is the most populous country in sub-Saharan Africa and the tenth most populated country in the world. Its estimated population of 162 million is spread across more than 250 ethnic groups. Given the association of women's autonomy with several health outcomes, it is essential to have a better understanding of the perceived decision-making autonomy of Nigerian women and the factors associated with their decision-making autonomy. Nigeria is particularly desirable for studying factors that affect women's autonomous decision-making because its great diversity provides an opportunity to disentangle various factors. For example, Nigeria has multiple religions with Christianity and Islam being the dominant religions, it is divided into six regions reflecting geo-political groupings and has a wide range of education and income levels. How these factors influence women's decision-making autonomy for their own health care is poorly studied in Nigeria. Furthermore, a study of Nigeria may serve as a case study for similar diverse countries in sub-Saharan Africa. This study aimed to utilize empirical evidence from nationally representative data to systematically describe women's selfreported health care decision-making autonomy and associated socio-demographic factors. Specifically, it describes Nigerian women's responses to the Nigerian Demographic and Health Survey question 'Who usually makes decisions about health care for yourself?' as an indicator of decision-making autonomy about their own health care and the factors independently associated with their responses. The study hypotheses were that: i) there are regional differences in Nigerian women's decision-making autonomy about their own health care, as indicated by the NDHS question; ii) socio-demographic and other factors are independently associated with Nigerian women's decision-making autonomy about their own health care. --- Methods --- Data Data were from the 2013 NDHS, a nationally representative study of socioeconomic characteristics, reproductive patterns and health behaviours of reproductive-age women in Nigeria. The survey was locally implemented by the Nigerian National Population Commission but funded by various international bodies including the US Agency for International Development , the UK Department for International Development and the United Nations Population Fund . The relevant data for this project, including individual characteristics, husband/partner's characteristics and measures of women's autonomy, were captured in the 2013 NDHS women's individual dataset. A total of 38,948 women aged 15-49 years were surveyed in the 2013 NDHS. Eligible participants for this analysis included women who: were married or had a partner; were living with their husband/partner at the time of interview; and answered the question about who usually decides about respondent's health care. Overall, 27,217 women met these criteria. Respondents who answered 'other' or 'someone else' to the decision-making question were excluded, leaving a final unweighted sample size of 27,135. --- Outcome variable The outcome variable was 'women's decision-making for their own health care'. This was the response to the question: 'Who usually makes decisions about health care for yourself?' Possible responses were: '[respondent] alone'; 'husband/partner alone'; '[respondent] and husband/partner jointly.' Women who answered 'husband/partner alone' were considered to have the least autonomy of the three groups. This group of women was contrasted with those whose response was 'respondent alone' and, in a separate comparison, with women whose response was 'respondent and husband/partner jointly', since the dynamics of autonomy represented by women reporting sole decision-making may differ from those reporting joint decision-making with husband/partner. --- Variables associated with women's health care decision-making autonomy Variables investigated for association with women's response to the question about health care decision-making included: region of country, rural/urban residence, respondent's age, education, religion, exposure to the mass media , ownership of house, ownership of land, wealth index, currently working, occupation, type of marriage, number of children and age gap between respondent and husband/partner. Certain socio-demographic characteristics of the husband/partner were also examined, including husband/partner's education and occupation. The NDHS wealth index was a composite derived measure of a household's cumulative living standard and relative wealth, calculated using data on a household's ownership of selected assets, including televisions and bicycles; materials for housing construction; and types of water access and sanitation facilities. The resulting index was then presented in ordered categories: 'poorest', 'poorer', 'middle', 'richer' and 'richest'. For the purpose of statistical modelling, several variables were re-coded into two groups, including: respondent's age: 15-34 years and 35-49 years ; type of marriage: monogamy and polygamy ; house or land ownership: 1 for women who owned such property and 0 for those who did not; place of residence: rural or urban . Other variables were indexed as follows. Education was represented by three indicator variables, with women with no education as the reference group and primary, secondary and higher education as the other categories. Respondent's religion was coded with Islam as the reference category and Catholic, Other Christian and Traditional/other religion as the other categories. Occupation was categorized as unemployed, non-professional and professional , with unemployment as the reference category. Wealth index was represented by four indicator variables with 'poorest' as the reference group. Region was encoded into five categorical variables with the North West region as the reference group. Exposure to the media variables were each re-coded into two indicator variables with 'not at all' as the reference category and 'less than once a week' and 'at least once a week' as the other categories. --- Data management and statistical analysis Data management and analysis were done using SPSS version 14. The NDHS sample weights were applied in all analyses. The distribution of responses to the autonomy question was explored using univariate statistics and association with socio-demographic variables using bivariate statistics. Multivariate logistic models were used to identify factors independently associated with women's decision-making autonomy about health care. The first multivariate model evaluated the woman's sole decision-making about her health care compared with sole decision-making by the husband/partner as the outcome variable and included the following independent variables: region of country, place of residence , respondent's age, education, religion, exposure to the mass media , ownership of house, ownership of land, wealth index, currently working, occupation, type of marriage, number of children, age gap with husband/partner, husband/ partner's education and husband/partner's occupation. The second model had joint decisionmaking with the respondent's husband/partner versus sole decision-making by the husband/ partner as the outcome variable and the same independent variables as the first model. --- Results --- Characteristics of respondents The characteristics of the women included in the study are shown in Table 1. The largest proportions of women were in the North West region. Nearly two-thirds resided in rural areas, only 7.3% had above secondary education, while 48.5% of the women had no formal education and nearly 40% of respondents' husband/partners had no formal education. The distribution of the women by religion was: 60.5% Muslim, 37.9 % Catholic and other Christian, with only 1.6% of women reporting 'other religious traditions'. Nearly a quarter of the women belonged to the poorest wealth index. More than half of the women said they could not read at all and 28.7% of the women reported not working at the time of the survey. Regarding husband/partner's occupation, 31.6% were agricultural employees, 19.5% were clerical sales persons and another 19.7% had skilled manual jobs. One-third of women were in polygamous relationships, i.e. had spouses who were concurrently married to other women. Media exposure variables showed that 84.7% reported not reading newspapers or magazines at all, 37.9% did not listen to the radio at all, 52.4% reported not watching television at all while 30.3% said they watched television at least once a week. Among respondents currently working, 60% of the women said they earned less than their husbands. A large proportion of the women in the survey reported that they did not own a house or land, while 21.0% and 17.3% reported owning a house and land, respectively. --- Decision-making about health care Only 6.2% of women reported making their own decisions about health care, while 61.1% reported that health care decisions were made by husbands/partners alone and 32.7% that health care decisions were made jointly. The distribution of responses for who makes decisions about the respondent's health care by socio-demographic characteristics is shown in Table 1. There were considerable and significant differences in who makes the decision about the woman's health care by region . Only 1.5% of women in the North West region made their own health care decisions, and 16.6% in the South West region, while the proportion of women for whom husbands/partners made the decision alone ranged from 27.2% in the South West to 83.8% in the North West. --- Factors associated with women making decisions alone about their health care The results of the logistic models used to identify factors associated with the question 'Who usually makes decisions about health care for yourself?' are shown in Table 2. Factors that were independently and significantly associated with woman making the decision alone included: region, rural/urban residence, respondent's age, education, religion, wealth index and occupation, as well as ownership of home and husband's occupation. The latter two variables were negatively associated with women making health care decisions alone. On the other hand, factors that were not independently associated included the respondent's exposure to print media, radio or television, whether currently working, land ownership, number of children, age gap between husband/partner and husband/partner's education. The region of the country was significantly associated with the outcome variable . While women in the North East region did not differ substantially from those in the North West region, women from the South South region were four times more likely than those from the North West, while those from the South West region were 8.3 times more likely, to make their own health care decisions than women in the North West. Older women were significantly more likely to make decisions alone compared with younger women. Women's place of residence also had a strong association; rural women were less likely to make their own decisions compared with their urban counterparts . Education also affected women's decision-making. Women who had attended secondary school were twice as likely to make their own decisions compared with those with no education, while those with higher and primary education were 1.57 and 1.70 times more likely, respectively, to make decisions alone. Regarding religion, Catholic women and other Christians were more than 2.5 times more likely to make their own health care decisions than Islamic women. Women in polygamous marriages were 1.82 times more likely to be autonomous in decisions-making compared with women in monogamous relationships . The likelihood of women making decisions alone increased monotonically with wealth index. Richer and richest women were 2.21 and 2.42 times, respectively, more likely than the poorest women to make decisions alone. Compared with women with unemployed husbands/partners, women whose husbands/partners were professionals or non-professionals were significantly less likely to make health care decisions alone . --- Factors associated with joint decision-making by the woman and her husband/partner on her health care Table 2 also shows the result of logistic regression done to identify independent variables associated with joint decision-making between the respondent and her husband/partner versus sole decision-making by the husband/partner. Factors significantly associated with joint decision-making included: region, woman's age, education, religion, exposure to print media, radio or television, ownership of land and house, wealth index, marriage type and husband's occupation. Unlike significant factors for women who make their own decisions, the coefficient on place of residence was not significant, whereas exposure to media and ownership of a house and land were significant. Neither age gap between husband/partner nor number of children was statistically significant for either comparison . Older women were more likely to participate in joint decision-making on their own health care than younger women . Women in the South West region were four times more likely to take part in joint decision-making than women from the North West region. Similarly, women of the Catholic faith and other Christians had higher odds of participating in joint decision-making with their husband/partner compared with women of the Islamic faith. Listening to radio and exposure to print media were positive predictors of joint decision-making, while watching television was negatively associated. Notably, compared with women whose husbands/partners were unemployed, women whose husbands/partners were professionals or non-professionals were significantly less likely to make health care decisions jointly . As wealth index increased, respondents were more likely to make joint decisions with their husband/ partner about health care. Women who were in the richest category were 2.36 times more likely to be part of joint decision-making than those in the poorest category. Interestingly, women whose husband/partner had primary education were more likely to participate in joint decision-making than those whose husbands/partners had no education, while secondary or higher education showed no significant association . --- Discussion Women's decision-making autonomy is constrained in many societies, especially in low-and middle-income countries. Studies of women's autonomy in developing countries first emerged in the context of reproductive health, women's nutritional status and child health outcomes . In contrast, few studies have focused on women's decision-making autonomy in the context of their own health care needs that are unrelated to reproductive health. Three important findings emerged from the present study: health care decisions for women in Nigeria are most often made by their husbands/partners without women's involvement; many socio-demographic factors were found to be independently associated with Nigerian women's decision-making autonomy, the strongest of which was region of the country; and socio-demographic factors suggest that joint decision-making between a women and her husband or partner is more similar to a woman making her own decisions about health care, thus suggesting some level of decision-making autonomy. A low level of women's decision-making autonomy in Nigeria is vividly illustrated by the observation that only 6% of women in the study sample made their own decisions about health care and one-third made decisions jointly with their husband/partner. For the majority of Nigerian women , health care decisions were made by their husband/ partner alone. This finding is consistent with studies of nationally representative samples in Asia, which found only a small minority of women made decisions alone for their own health care . In that survey, in the majority of households women's health care decisions were made without women's participation, much like what was found in this study in Nigeria. Other studies found a similar pattern. For example, Mistry et al. , in a study in rural India, found that more than half of the women were not involved in decisionmaking about their own health care. Similarly, Rahman et al. found that more than one-third of women in a Bangladeshi study were not involved in decision-making about their own health care. Overall, despite differences in study sites, study design and analytic methods, these data are consistent with those of other studies that show that very few women in multiple low-and middle-income countries make their own decisions about health, indicating a prevalent low level of women's decision-making autonomy regarding their own health care. Several factors were found to be independently associated with women's decision-making autonomy in Nigeria, including: region of the country, rural/urban residence, respondent's age, education, religion, wealth index and occupation, as well as home ownership and husband/partner's occupation. A recent review of studies of women's autonomy in low-and middle-income countries found that many of these factors are common correlates of women's autonomy across multiple societies in Asia and Africa. Reasons for the association of factors such as age, education, occupation, wealth and income with women's autonomy have been reviewed . The present data found positive associations between decision-making autonomy and wealth index, urban residence and education, as has been reported elsewhere , and women with no education have less autonomy than those with secondary and higher education. Of note, no relationship was found between decision-making about a woman's own health care and the woman's employment status or the number of children she had, once other factors had been controlled for. This is in contrast to previous findings that working women are more likely to participate in decision-making, and the more children women have, the more likely they are to participate in decision-making . The strongest association with women's decision-making autonomy was the region of the country in which they lived. As hypothesized, region was an important determinant of a woman's decision-making autonomy, even after controlling for individual and household factors. Notably, other studies have also found that geographic region was significantly and independently associated with women's autonomy after controlling for other variables. These findings suggest that there are factors associated with geographical region that are not captured by many surveys. For example, a study in India found that women in the southern region of India have more exposure to the outside world, a greater voice in family life and more freedom of movement than do those in the north . Such factors were not captured in the DHS instrument used in the present study. In Nigeria, family life is guided by normative principles, institutions and belief systems that derive from ethnicity and culture. Such factors as cultural beliefs and ethnic group are important components of regional variation, and may explain the independent influence of region on women's autonomy. A previous study of Nigerian women that specifically set out to study the effects of this noted that ethnicity is a major determinant of whether Nigerian women receive formal education, have a say in selecting their spouses, live with a mother-in-law, work outside the home and control income . Regions of Nigeria also represent geo-political zones that exhibit differences in history, length of contact with Western education, unequal access to education, the prevalence of Islam and ethnic composition. Indeed, it was recently shown that women's participation in household decision-making was lower in Nigerian states that introduced Sharia law into secular life . Thus, there are important community-level factors that shape women's decision-making autonomy beyond the usual individual-level factors . Joint decision-making with a husband/partner was examined separately from decisions made by a woman alone about health care. While it is apparent that health care decisions made by the husband/partner alone without the participation of the woman represents the lowest level of decision-making autonomy for the woman, joint decision-making may represent a level of partnership or equality within the couple that is harder to explain in terms of decisionmaking autonomy. Indeed, it was found that similar factors were associated with decision-making by the woman alone and jointly with her husband/partner . Secondly, the associated effect sizes were usually in the same direction for decision-making by the woman alone and jointly with husbands/partners. These observations support the notion that joint decision-making by the woman and her husband/partner may not represent a lower level of autonomy for women than decision-making by the woman alone. Joint decision-making deserves further study. The study has a number of limitations. This was a secondary analysis of survey data with responses obtained by self-report. This means the responses were subject to recall and reporting bias. Survey questions have limited ability to capture the nuance and context of responses, and preclude clarification of responses through open-ended follow-up questions. For instance, when a woman reports making health care decisions jointly with her husband/partner, it could indicate equity in the relationship or could be an indicator of lower autonomy for the woman because she is not allowed to make such decisions alone. Similarly, although making decisions alone by the woman was interpreted as representing more autonomy, it could indicate lack of support from the husband/partner who would rather not be involved. Without follow-up questions/ prompts or qualitative data, it is uncertain which interpretation is appropriate. Further, in common with other surveys, the questions may not have been understood the same way by all participants. While a large number of potential explanatory variables were captured in the survey, some other variables were not directly captured. Some of these issues could affect the internal validity and/or generalizability of these findings, but a study based on secondary data has limited ability to control for issues in study design, instruments and/or implementation. Therefore, the data were compared with previous regional or national data from Nigeria and broadly similar findings were found. The responses to another question asking the woman if her need to obtain permission constituted a barrier to seeking health care were also examined, and broadly similar consistency were found with the findings of this study with regards to association with geographical region, income, education and occupation . These observations provide confidence for the validity of the findings. At the same time, these data were derived from a nationally representative sample of a large number of women. A better understanding of factors affecting women's decision-making autonomy can inform the design and implementation of health programmes and policy. For example, if men wield such power in decision-making for their wives/partner's health care, the target of health education programmes has to include men. On the other hand, targeting modifiable factors that increase women's decision-making autonomy in a community would not only enhance women's autonomy, but could also lead to better health care outcomes as women gain more control over their lives and health. Factors that are not individual-level factors should be taken into account when designing and implementing health programmes. Using this study as an example, a national one-size-fits-all approach is likely to encounter varying degrees of success because of regional variation. Tailoring some health interventions to specific regions may be essential to account for the unique dynamics of health care decision-making of each region. In conclusion, using data from a large, recent nationally representative survey of Nigerian women, more than half of the women reported that they have no say in decision-making about their own health care. Factors associated with women's decision-making autonomy included individual-level factors as well as other factors, in particular geographic region. Decision-making varied dramatically between regions in Nigeria even after controlling for other factors, indicating other unmeasured factors that influence decision-making about health care. Future studies are needed to provide context to these findings using qualitative methods, to examine the issue of joint decision-making and evaluate decision-making for different components of health care , for which decision-making may differ. Odds ratios for selected variables independently associated with women making decisions alone about her health care and joint decision-making with her husband/partner.

Women's decision-making autonomy has been poorly studied in most developing countries. The few existing studies suggest that it is closely linked to women's socio-demographic characteristics and the social settings in which they live. This study examined Nigerian women's perceived decision-making autonomy about their own health care using nationally representative data from the 2013 Nigerian Demographic and Health Survey. The study sample consisted of 27,135 women aged 15-49 years who lived with their husbands/partners. Responses to questions about who usually makes decisions about the respondent's health care were analysed. Factors associated with women's health care decision-making were investigated using logistic regression models. Only 6.2% of the women reported making their own decisions about health care. For most women (61.1%), this decision was made by their husband/partner alone and 32.7% reported joint decisionmaking with their husband/partner. Factors independently associated with decision-making by the woman included: geographical region, rural/urban residence, age, education, religion, wealth index, occupation, home ownership and husband's occupation. A strong association between women making their own health care decision was seen with region of residence (χ 2 = 3221.48, p < 0.0001), even after controlling for other factors. Notably, women from the South West region were 8.3 times more likely to make their own health care decisions than women from the North West region. Factors that were significantly associated with joint health care decision-making were also significantly associated with decision-making by the woman alone. The study found that individual-level factors were significantly associated with Nigerian women's decision-making autonomy, as well as other factors, in particular geographic region. The findings provide an important perspective on women's health care decision-making autonomy in a developing country.

INTRODUCTION Thirty-day rehospitalizations affect 1 in 5 hospitalized Medicare patients, cost over $17 billion annually, and result in hospital-based Medicare payment penalties for congestive heart failure, pneumonia and acute myocardial infarction rehospitalizations . Most believe that all hospitals can prevent at least some rehospitalizations by using a spectrum of programs to better support vulnerable patients during the high-risk post hospital period . Yet, the targeting of these programs has proven challenging, potentially because important factors contributing to rehospitalizations are not well measured-like socioeconomic disadvantage . Socioeconomic disadvantage is a complex theoretical concept, which describes the state of being challenged by low income, limited education and substandard living conditions for both the individual and their neighborhood or social network . Detailed assessment of an individual patient's socioeconomic status is a time-consuming and potentially uncomfortable task to add to a clinical encounter, and since such information is rarely available in the patient's medical record, clinical teams often overlook socioeconomic factors when creating individualized post-hospital care plans . Alternatively, measures of neighborhood socioeconomic disadvantage, such as concentration of poverty in the neighborhood surrounding the patient's residence, could be more easily accessed and assigned as a risk factor at the point of patient admission by using the patient's address. However, the association between neighborhood disadvantage and rehospitalization risk has not yet been established. It is plausible that neighborhood socioeconomic disadvantage would influence rehospitalization risk, because vulnerable patients depend on neighborhood supports for stability generally , and these needs are likely to be increased in the period after hospital discharge . US safety-net hospitals, which serve socioeconomically disadvantaged areas, are more apt to be financially penalized for their rehospitalization rates . Living in a socioeconomically disadvantaged neighborhood has been associated with health behaviors , access to food and safety , and with outcomes such as mortality , birth weight , and rehospitalization risk for heart failure . Additionally, important health indicators improve with moving people to areas of less concentrated poverty . In 2003, Singh created a composite measure of neighborhood socioeconomic disadvantage for the US --the Area Deprivation Index --based on similar measures used in many other countries for resource planning and health policy development . The ADI is a factor-based index which uses 17 US Census poverty, education, housing and employment indicators to characterize census-based regions , and has been correlated with a number of health outcomes including all-cause, cardiovascular, cancer and childhood mortality, and cervical cancer prevalence . Socioeconomic disadvantage based on neighborhood risk through a Zip code-linked ADI does not require a potentially lengthy and intrusive discussion with patients and families, and could be easily made available to clinical teams and policymakers. Our objective was to determine whether or not neighborhood socioeconomic disadvantage could be useful to clinical planning by examining its relevance in a population likely to be targeted by clinical improvement activities designed to reduce readmission risk. We analyzed the association between ADI, defined at the census block group level, and 30-day rehospitalizations for patients discharged with congestive heart failure, pneumonia or acute myocardial infarction, the clinical conditions used for the current calculation of Medicare's rehospitalization penalties. --- METHODS --- Data Sources, Study Population We used 2004-2009 data from the Chronic Condition Data Warehouse , including Medicare claims and enrollment files pre-linked to annual Medicare provider of service files for a 5% random national sample of Medicare beneficiaries. Beneficiaries who received railroad retirement benefits or were in a health maintenance organization were excluded because these groups have incomplete data. We identified 307,827 patients >65 years of age hospitalized with congestive heart failure, acute myocardial infarction or pneumonia using Medicare readmission measure definitions . We used the Zip+4 code listed for the patient's residence within Medicare data to link to the census block group with the same Zip +4 area in 2000 US Census data for the 50 US States and District of Columbia. Each census block group covers an area of 600-3,000 people, averaging 1,500 people . We excluded 52,083 patients without a Zip+4 code in their Medicare data or whose documented Zip+4 code did not exist in the 2000 Census data . Patients in this latter category may include those who designate a post office box as their primary residence, or reside in post-year 2000 new Zip+4 areas, US Territories or institutions like prisons. Hand-checking of a small random sampling of these patients' Zip+4 codes suggests that most were assigned to a post office box. The final sample size was 255,744 patients. These patients originated from 4,802 unique hospitals . The University of Wisconsin Institutional Review Board approved this study. --- Variables Census Block Group-Level Variables-We calculated ADI scores for each US Census block group using Singh's methodology . This involved summing Singh's 17 Census indicators weighted by Singh's factor score coefficients for each indicator . See Appendix 1 for more detail on constructing the ADI. We examined the distribution of ADI values and sorted neighborhoods into percentiles by increasing ADI. Patient-Level Variables-We constructed all-cause rehospitalization within 30 days of discharge from Medicare claims . Other variables drawn from Medicare files, included patient age, gender, race, Medicaid status, initial Medicare enrollment due to disability, index hospitalization length of stay and discharge to a skilled nursing facility. Race was categorized into 'White', 'Black', and 'Other' based upon the beneficiary race code. Each patient's Centers for Medicare and Medicaid Services hierarchical condition category score, calculated from all outpatient and inpatient claims over the 12 months prior to the index hospitalization, was included as a risk adjustment measure . Comorbid conditions were identified using Elixhauser methods, incorporating data from the index hospitalization and from all hospitalizations and physician claims during the year prior to the index hospitalization . Of the comorbidities identified using this approach, 17 had frequencies of greater than 5% in the sample and were included as indicators. Comorbidities occurring less often were compiled into an 'other comorbidity' indicator and included alcohol/drug abuse, rheumatoid arthritis/collagen vascular disease, chronic blood loss anemia, liver disease, lymphoma, metastatic cancer, solid tumor without metastases, paralysis, psychoses and peptic ulcer disease. We assessed rurality of each patient's zip code of residence using the US Department of Agriculture's Rural/Urban Commuting Area Codes, grouped into categories of "urban core areas," "suburban areas," "large town areas," and "small town/isolated rural areas" . Index hospital characteristics, including Medicare geographic region, for-profit status and medical school affiliation, were drawn from the Medicare provider of services file corresponding to the patient's index hospitalization date . We estimated annual Medicare discharge volume for each hospital by multiplying the number of claims from each hospital in the 5% national sample, by 20. We then grouped hospitals into low, middle and high volume tertiles. About one percent of our sample was missing race data , and less than 3% were missing hospital medical school affiliation and for-profit status . There were no missing data for other patient-level variables. --- Statistical Analysis We examined the unadjusted relationship between ADI percentile and 30-day rehospitalization, overall and by primary disease. Based upon the empiric ADI data, the most disadvantaged neighborhoods made up the top 15% of the distribution. To better assess for within-group differences, we divided this most disadvantaged 15% into three equally sized 5% groupings representing the third-most, the second-most and the most disadvantaged 5% of neighborhoods. The remainder of neighborhoods were grouped into a comparator category. We examined frequencies of patient and index hospital characteristics for each grouping. We used logistic regression to assess the relationship between ADI grouping and 30-day rehospitalization. Next, to assess the full spectrum of ADI impact, we divided the distribution into 20 equally-sized neighborhood groupings of increasing ADI , and used logistic regression to assess the relationship between ADI grouping and rehospitalization. To investigate the within-hospital ADI effects , we employed conditional and random effects logistic regression . To assess for differences in disease grouping and rural-urban effects, the relationship was assessed using logistic regression models stratified by disease grouping and RUCA code. Patient numbers in stratified analyses were smaller, so we analyzed the most disadvantaged 15% of neighborhoods as a single group. Control variables were drawn from theoretical models of rehospitalization and included patient HCC score tertile, comorbidities, length of stay, discharge to skilled nursing facility, age, gender, race, Medicaid status, disability status and RUCA code of primary residence; and index hospital medical school affiliation, for-profit status and discharge volume tertile. We calculated adjusted risk ratios, predicted probabilities, and 95% confidence intervals from these models on the basis of marginal standardization, as per methods by Kleinman and Norton and by Localio . All models were estimated twice-once accounting for hospital-level and patient-level clustering, and again using robust estimates of the variance. Since no differences were noted, we present the more conservative robust estimates. All analyses were performed using SAS 9.3 and STATA 12 . --- Role of the Funding Sources --- RESULTS --- Neighborhood and Patient Characteristics by ADI Grouping Patients in the most disadvantaged 15% of neighborhoods were more apt to be Black, on Medicaid, and to have higher rates of comorbidities, especially congestive heart failure, chronic pulmonary disease, and hypertension than patients from the other 85% of neighborhoods . They were also more likely to have been hospitalized in a forprofit hospital. The majority of patients in the most disadvantaged 5% of neighborhoods lived in urban core areas. Those in the second-and third-most disadvantaged 5% groups were most likely to live in rural or large town areas. --- Day Rehospitalization and Patient Neighborhood ADI When compared to the other 85% of neighborhoods, residence within the most disadvantaged 15% of neighborhoods was associated with an increased risk of 30-day rehospitalization. The 30-day rehospitalization rate did not vary significantly across the least disadvantaged 85% of neighborhoods with an average rate of 21%. However, within the most disadvantaged 15% of neighborhoods, rehospitalization rates rose from 22% to 27% with worsening ADI . This pattern was maintained in all three primary diagnoses. After adjustment, residence within the most disadvantaged 15% of neighborhoods continued to be associated with increased rehospitalization risk, with the most disadvantaged 5% having the greatest risk . The adjusted rehospitalization risk ratios associated with residence within the most disadvantaged 15% of neighborhoods were similar to those of chronic pulmonary disease and peripheral vascular disease, and greater than those associated with having diabetes or being on Medicaid . This association was noted across all primary diagnoses . Sensitivity analyses, including conditional logistic regression models with control for hospital, also suggest that when comparing two patients, otherwise the same, who differ by reason of neighborhood deprivation index and arrive at the same hospital, the association of deprivation and readmission remains . --- Geographic Distribution The prevalence of the most disadvantaged neighborhoods varied by Medicare geographic region . Certain regions, like the Dallas, Atlanta, Chicago and Philadelphia regions, had a higher proportion of Medicare patients with the penalty-eligible conditions of congestive heart failure, pneumonia or acute myocardial infarction residing in the most disadvantaged US neighborhoods, than other regions. Some regions, like the Seattle region, had less than 5% of all eligible patients living in such neighborhoods. Figure 2 shows the locations of the most disadvantaged US patient neighborhoods in this study. The distribution of the most disadvantaged neighborhoods also varied by rural-urban status. Nearly one-third of eligible patients residing in rural areas lived in neighborhoods that were among the most disadvantaged . However, residence in the 15% most disadvantaged neighborhoods was a rehospitalization risk regardless of rural-urban area type. --- DISCUSSION Living in a severely disadvantaged neighborhood predicts rehospitalization as powerfully as does the presence of illnesses such as peripheral vascular disease or chronic pulmonary disease, and more powerfully than being on Medicaid or having diabetes. This effect holds after accounting for other patient-and hospital-level factors known to influence risk of rehospitalization, including race. Overall, patients from disadvantaged neighborhoods are at higher risk for rehospitalization regardless of their treating hospital. Our findings suggest that neighborhood disadvantage is associated with a threshold effect, with strong and increasing risk of rehospitalization for residents of the most disadvantaged 15%. This threshold effect conforms with fundamental theories of social disadvantage which indicate that there is generally some point beyond which individuals can no longer compensate and additional disadvantage leads to increasingly adverse outcomes . A wealth of social science research demonstrates that 'areas of concentrated poverty' place additional burdens on poor families that live within them, beyond the effect of the families' individual circumstances . It is clear that social support and a patient's environment can influence clinical outcomes, including rehospitalizations. Although most clinicians would agree with our findings, in practice issues of socioeconomic disadvantage are often overlooked for three reasons: 1) we do not agree on how to measure disadvantage, 2) we lack time and hesitate to ask for highly personal data, and 3) we do not always know what to do about disadvantage when we find it. These barriers have diminished recently. The ADI, which is widely studied and predicts rehospitalization, provides a useful measure that is usable right now, although better measures may be developed in the future. Because the ADI relies entirely on publicly-available census data, and will be available free on-line through the University of Wisconsin Health Innovation Program in the form of a Zip+4 code-ADI file as well as an individual look-up tool requiring only the patient's Zip+4 code to query, it avoids both the time burden and the intrusiveness of collecting sensitive data from the patient. Based on patient address alone, clinicians and health systems could, at the point of first contact, use the ADI to screen for patients returning to the most challenging environments; supporting early targeting of more intensive transitional care services, prompting discussion of socioeconomic environment and need, and activating additional community resources for these patients. Transitional care interventions decrease rehospitalizations by employing a series of interactions designed to empower patients, monitor for early signs of disease worsening, and ensure medical plans and follow-up are in place. The targeting of transitional care programs can sometimes be challenging, especially in low-resource health settings. We offer the ADI as a potential way to refine such targeting. Placing a look-up table in a hospital's admission-processing system to supply this high-risk screener to the clinical team should be a very modest technical challenge. Some European countries use composite measures of neighborhood socioeconomic disadvantage similar to the ADI to monitor population health and to allocate services and funding to ensure increased support in high-risk regions . It could be used similarly in the US to refine characterizations of hospital service regions. Health systems and other health-related institutions could also use the ADI to identify neighborhoods that would most benefit from additional outreach and services. Policymakers could test innovative strategies for improving living conditions for older adults in severely disadvantaged areas . Finally, ADI scores could be used to direct funding towards community-based initiatives designed to lower unwanted rehospitalizations . Medicare hospital readmissions penalties fall more heavily on hospitals serving disadvantaged neighborhoods than on other hospitals . Adjusting for the socioeconomic status of individuals served might level the playing field, but so far the debate has centered on the role of personal socioeconomic disadvantage in readmission risk, which remains unclear , and evidence that personal indicators of disadvantage are not ideally reliable or valid for elderly populations . Using the ADI to identify patients from the most severely disadvantaged neighborhoods could be explored as an adjuster for the current Medicare readmissions measures; one that might avoid the limitations of personal socioeconomic indicators and better screen for readmission risk. A number of factors should be considered when interpreting these findings. To be included in our analyses a patient had to have a zip code of residence included within 2000 Census data. Therefore, the results of this analysis may not apply to patients without zip codes, such as the homeless, and those with zip codes absent in 2000 Census data. Although many of these latter patients list a post office box with Medicare, hospitals would have ample opportunity to gather residential Zip+4 codes directly. Census data collected in 2000 may not fully reflect neighborhood characteristics in the between-Census years of 2004-2009 used in this study. Next, patient-level analyses of any geographic-based measure, including the ADI, can introduce an ecological fallacy in which a region's aggregate traits are inappropriately attributed to a particular individual. However, our suggested use of the ADI as a clinical screener, which could trigger clinical teams to more fully assess for postdischarge need, should avoid this problem. Finally, the administrative data on which we relied does not contain direct markers of care quality or access that may affect rehospitalization risk. It is possible that hospitals that serve predominantly disadvantaged neighborhoods provide different quality of care than hospitals that serve predominantly nondisadvantaged neighborhoods and this had an influence on our findings . The available data do not allow for a definitive conclusion in this regard but there is no clear evidence that safety-net hospitals, in general, differ from non-safety-net hospitals in their quality of care . Our analytic models provide evidence that the patients' neighborhood remains a strong predictor of rehospitalization regardless of other hospital-level factors. More robust data should be utilized to study these across-hospital effects in the future. The effects associated with neighborhood disadvantage may result from person-level socioeconomic disadvantage for which community data are a proxy . In studies of child health and mental health outcomes, neighborhood disadvantage has been demonstrated to be an additional risk factor beyond personal disadvantage, with worse health and social outcomes for individuals who live in both poor families and poor neighborhoods than for individuals living in poor families in less poor neighborhoods . Our main aim was to produce a meaningful estimate of disadvantage that could be easily used by clinicians and discharge planners. The relative importance of individual and community disadvantage cannot be determined from our data. Clarifying these associations deserves further study. We chose the ADI for this analysis because it is a well-established US census-based measure which provides a composite view of socioeconomic disadvantage for all areas of the US and which can be used to reliably 'drill-down' to a relatively small geographic region . Others have explored using single income-related component measures as socioeconomic markers , but single construct approaches likely miss issues critical to post-hospital planning, such as education and living conditions. This may be why income alone shows mixed results as a rehospitalization predictor in studies to date . In conclusion, residence within a disadvantaged US neighborhood is a rehospitalization predictor of magnitude similar to important chronic diseases. Measures of neighborhood disadvantage, like the ADI, are easily created using data already routinely collected by the US government and freely available to the public, and may be useful in targeting patientand community-based initiatives designed to lower unwanted rehospitalization. Using Singh's methods, these 17 indicators are weighted using factor score coefficients . Using these Singh factors score coefficients, poverty, income and education have the largest relative weights amongst all of the 17 variables. These 17 US Census variables are multiplied by their factor weights and then summed for each geographic unit. The result is then transformed into a standardized index by arbitrarily setting the index mean at 100 and standard deviation at 20 . Using this approach, neighborhoods with higher ADI scores have higher levels of deprivation . Typically, the ADI has been used to break geographic units into quintiles, deciles or other relatively ranked groupings by ADI score. To our knowledge, it has not been used as a predictor in its continuous, indexed form. For this study, we initially examined the distribution of ADI values and sorted neighborhoods into percentiles by increasing ADI. *Urban block groups/neighborhoods must be viewed at higher magnification within this figure, because they comprise smaller geographic areas than their rural counterparts. Enlargements of sample urban areas are offered to demonstrate. Percent of occupied housing units with more than one person per room 0.0556 * Components and factor score coefficients drawn from reference 28. All coefficients are multiplied by -1 to ease interpretation . † Income disparity defined by Singh as the log of 100*ratio of number of households with <$10,000 income to number of households with $50,000+ income. --- Table 2 --- Key --- Acknowledgments --- Dr. Kind had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. --- Appendix 1 CALCULATING THE SINGH AREA DEPRIVATION INDEX Introduction In their analysis and monitoring of health, Great Britain, Sweden, Australia, New Zealand and many other nations use area-based composite deprivation indices; scores created by compiling measures of socioeconomic resources within a particular geographic area . In 2003, Singh created a similar Area Deprivation Index for the US . The ADI is a validated, factor-based deprivation index which uses 17 poverty, education, housing and employment indicators drawn from US Census data to create a measure of socioeconomic context for a particular census-based region . The ADI has previously been used to document a number of socioeconomic-health associations, including the direct relationship between area deprivation and all-cause, cardiovascular, cancer and childhood mortality, and between area deprivation and cervical cancer prevalence . In the manuscript associated with this appendix, we calculated Area Deprivation Index scores for each block group/neighborhood using methods proposed by Singh as a way to assess the socioeconomic context of a patient's neighborhood. This appendix provides interested readers with a more detailed account of how we calculated the ADI using Singh's methods. --- Detailed Methods for Creating the ADI Singh's ADI uses 17 US Census variables in its construction. We calculated these for each geographic unit, in this case a census-block group, using publically available 2000 US Census data. The US Census variables are as follows: • Income disparity --- • Median home value Appendix Table All models employ multivariate logistic regression methods to assess the relationship between ADI grouping and 30-day rehospitalization to produce adjusted risk ratios for each diagnosis by using the methods of Kleinman and Norton . ‡ All models adjusted for: Hierarchical Condition Category Score; indicator variables denoting the presence of comorbidities including hypertension, fluid and electrolyte disorders, congestive heart failure, chronic pulmonary disease, deficiency anemias, uncomplicated diabetes, complicated diabetes, valvular disease, hypothyroidism, peripheral vascular disease, coagulopathy, depression, other neurological disorders, obesity, pulmonary circulation disease, renal failure, weight loss and other comorbidity; length of stay of the index hospitalization; and an indicator variable for whether a patient was discharged to a skilled nursing facility; patient demographics including age, gender and race , Medicaid status, disability status, and index hospital characteristics including medical school affiliation, for-profit status and total discharge volume tertile. Race data were missing for 291 patients. Index hospital medical school affiliation and for-profit status were missing for 777 patients.

Background-Measures of socioeconomic disadvantage may enable improved targeting of programs to prevent rehospitalizations, but obtaining such information directly from patients can be difficult. Measures of US neighborhood socioeconomic disadvantage are more readily available, although rarely employed clinically. Objective-To evaluate the association between neighborhood socioeconomic disadvantage at the census block-group level, as measured by Singh's validated Area Deprivation Index (ADI), and 30-day rehospitalization.Patients-Random 5% national sample of fee-for-service Medicare patients discharged with congestive heart failure, pneumonia or myocardial infarction, 2004-2009 (N = 255,744) Measurements-30-day rehospitalizations. Medicare data were linked to 2000 Census data to construct an ADI for each patient's census block-group, which were then sorted into percentiles by increasing ADI. Relationships between neighborhood ADI grouping and rehospitalization were evaluated using multivariate logistic regression models, controlling for patient sociodemographics, comorbidities/severity, and index hospital characteristics. Results-The 30-day rehospitalization rate did not vary significantly across the least disadvantaged 85% of neighborhoods, which had an average rehospitalization rate=21%. However, within the most disadvantaged 15% of neighborhoods, rehospitalization rates rose from 22% to 27% with worsening ADI. This relationship persisted after full adjustment, with the most disadvantaged neighborhoods having a rehospitalization risk (adjusted risk ratio = 1.09, confidence interval 1.05-1.12) similar to that of chronic pulmonary disease (1.06, 1.04-1.08) and greater than that of diabetes (0.95, 0.94-0.97).Conclusions-Residence within a disadvantaged US neighborhood is a rehospitalization predictor of magnitude similar to chronic pulmonary disease. Measures of neighborhood disadvantage, like the ADI, could potentially be used to inform policy and post-hospital care.

Contributions to the literature Ageism in Canada extends through many organizations and institutions, including healthcare. This study will build knowledge on the effectiveness of e-learning approaches in dispelling ageist misconceptions amongst student nurses. This study will generate evidence on the effectiveness of the three e-learning activities on student nurses' perceptions of older people. This study's partnership approach to knowledge mobilization can guide researchers seeking to involve key stakeholders and community-members in the development and implementation of strategies to improve healthcare education and delivery, enacting positive social change. --- Background --- Understanding ageism Canada has more people aged 65 and older than it has children 14 and younger [1], with ageism impacting many of these older Canadians. Butler [2] defines ageism as negative perceptions attributed to a population based on its age. Ageism includes negative attitudes towards older people, aging, and the aging process, as well as discrimination that is either individual or systemic [3]. Stereotypes of growing old include increasing illness, isolation, poverty, and depression contribute to ageism [4]. Further, negativity towards older people is accepted, without social sanctions [5], with the result that it flourishes in Canada. Ageism often emerges "insidiously, veiled in claims of 'best interest,' or humor" , as a socially acceptable form of discrimination. Most older Canadians live independently in the community and growing numbers continue to work after the age of 65 [7,8]. Unfortunately, they experience ageism when purchasing goods and services [9], in their familial relationships [10] and in healthcare institutions [11]. --- Impacts of ageism Research has demonstrated a negative association between age discrimination and older people's well-being [12] and self-esteem [13], and a positive association with depressive symptoms [14]. This suggests that negative stereotypes about aging can become internalized [13,14], so that conscious or unconscious ageist perceptions and stereotypes influence the cognitive and/or physical functioning of older people and erode their will to live [15]. Various international studies have reported the deleterious effects of ageism: healthcare costs in the United States due to health-related illness from ageism are estimated at $63 billion a year [16]. European-based studies have reported that older people are treated negatively and undervalued [17,18]. A 2008 Canadian study involving people of all ages reported that, regardless of culture and religious philosophy, Canadians view older people as "less vital" and "non-accommodating" ; the study also revealed that younger Canadians respect older people but want to avoid them. --- Aging in a nursing context Palmore [20] has called ageism a "virus" ingrained into cultures, so pervasive that even older people have negative stereotypes of aging. Thus, it is not surprising that ageism, in the form of poor care of older people, persists within healthcare, despite initiatives to improve their care and status [6]. Healthcare systems are designed for younger people, emphasizing efficiency and quick turnover, and do not consider the complexity of older people's health and social concerns [11,21]. This ageist perspective extends to the nursing profession, the largest group of healthcare professionals [22], with many nurses believing that working with older people is of low occupational status [23]. Scholars have suggested that nurses' ageist stereotypes exist because they see older people at their most vulnerable and dependent [24][25][26]. Additionally, when nurses hold negative stereotypes of cognitive and physical decline of older people [3]-and believe that working with older people is simple [24][25][26]-they fail to adequately assess and manage older people's healthcare concerns, leading to negative consequences [25,[27][28][29][30][31]. Conversely, when nurses have positive perceptions of older people, they are more likely to recognize older people's health and social needs and meet them appropriately [19,32]. A recent review of gerontological competency frameworks in Canadian health and social service education suggests the need for greater gerontological competencies across professions [33]. Canadian gerontological experts have developed gerontological competencies for nursing programs [34], and professional gerontological nursing standards and competencies to meet best practice expectations [35]. Unfortunately, these competencies have not been consistently incorporated into accreditation processes or curriculum revision initiatives and Canadian health and social service faculty are often unaware of published gerontological competencies that could aid them in curricular evaluation and optimization [36]. Barriers to integrating gerontological competencies include insufficient faculty expertise in gerontology and little recognition that gerontological competencies are needed [36]. If ageism was acknowledged, there would be a stronger impetus for implementing these competencies, thereby better serving older Canadians. Against this background, scholars have identified that nurses are graduating with inadequate knowledge about working with older people [37][38][39][40], including how to care for them [26,41]. Students observe what practitioners say and how they model care provision to older people, which can have a lasting impact on professional learning and socialization [42] and shape how student nurses learn to work with older people. Unfortunately, practicing nurses who demonstrate ageist behaviours towards older people unwittingly contribute to the professional socialization of students [24]. Our prior work revealed that practicing nurses and nurse educators often perpetuate student' negative perceptions and pass on negative practices to the next generation of nurses [43]. For instance, when students witnessed nursing staff not listening to older people or neglecting to attend to their needs, the students inferred that these patients were not a priority, and that older patients' concerns need not be addressed. Overall, students were not prepared for the complexity of the aging population, due to minimal curricular focus on older people, and lack of strong gerontologic role models [43]. Still, students wanted to learn more about aging and expressed interest in web-based and/or simulated learning activities. In another study, newly graduated nurses likewise identified the need for web-based learning activities that enhance knowledge about working with older people [44]. A critical review of the literature examining nursing education related to older people suggests that nursing programs have focused on integrating content about older populations into curricula, but not on the social aspects of learning processes that expose students to ageist perspectives and practices [45]. Certainly, students come from a wide range of cultures that contribute to socialization and beliefs about growing old, but they are also exposed to the negative stereotypes about aging embedded in nursing and healthcare cultures. Nursing programs reinforce uptake of these negative stereotypes and perpetuate ageism by privileging technical knowledge over gerontology-focused care [46]. Few nurse educators have gerontological expertise, which would enable them to actively dispel negative perceptions within nursing programs [37][38][39]47]. Taken together, the dearth of gerontology-prepared nursing faculty, insufficient gerontological content, and learning experiences in nursing programs that perpetuate stereotypes of aging create negative care experiences for older Canadians. --- Study objectives and significance A partnership with Canadian organizations that advocate for older people and the involvement of gerontological experts is needed to bring this awareness to the public and professionals that work with older people. Accordingly, we have the following three objectives: 1. To test if we can displace ageist perspectives, we will use student nurses as a test sample to determine if innovative e-learning activities aimed at dispelling aging myths improving students' perceptions of older people and reduces negative stereotypes of growing old. 2. To develop short-, medium-, and long-term strategies, based on the test results, aimed at dispelling negative stereotypes about aging in professional groups that serve older people and the Canadian public. An advisory group consisting of older Canadians and representatives from CanAge, HelpAge, Canadian Gerontological Nursing Association , and academic gerontological experts will be assembled to tackle this challenge and identify appropriate methods to bring positive messages about aging to Canadians. 3. To implement the short-term strategies developed by the advisory group. The specifics of the implementation plan will solidify as findings from testing the e-learning activities with student nurses and discussion with the advisory group are developed into strategies. This project will improve how older people are treated in healthcare by creating awareness of ageism towards older Canadians, defined as people aged 65 and older [48]. Palmore [20] purports that the best way to reduce ageism is to bring awareness to it-our overarching aim-by developing strategies to dispel negative stereotypes about aging. We choose to address negative aging stereotypes in student nurses based on the findings of our previous research, but also because nurses, who are influential in healthcare teams, can model positive practice. If student nurses' perceptions towards older people can be improved, other professionals and the Canadian public's perceptions may be similarly improved to enhance service to older Canadians. Importantly, implementing the short-term strategies we develop will rapidly mobilize the initial research findings, but the project also has the potential to leverage relationships amongst the partners to implement medium-and longterm strategies. --- Theoretical framework: social learning theory Bandura's social learning theory which proposes that people learn new behaviours through observations in their social environments [32] will guide each step of this study. Social learning theory illuminates how people learn in society and proposes that behaviour and beliefs are often attributed to underlying forces that can be modified or eliminated with a new stimulus or learning approach. Student nurses, for example, learn in complex social environments that straddle classrooms and clinical settings, where they are exposed to healthcare professionals who may unconsciously be perpetuating negative behaviours towards older people [49]. Social learning theory will spur the project team to be attentive to the multiple ways that learning occurs and the importance social context plays in learning. The theory will direct our development of knowledge mobilization strategies to dispel negative stereotypes amongst Canadians and test student nurses' perceptions about older people, following the elearning activities, by focusing on the social aspects of how people learn, i.e., through the images they see, the messages they hear, and the behaviours related to ageing and older Canadians that are modeled for them. We propose that as student nurses' perceptions improve and they acquire accurate knowledge, the current inadequate assessment and management of older people's healthcare concerns, embedded as they are with ageist stereotypes, will dissipate [27,29,31]. Social learning theory will additionally guide us in analyzing the data, interpreting the findings, and knowledge mobilization, through careful attention to social contexts that influence how people perceive and behave towards older people. --- Methods/design To raise awareness of ageism in Canada, this quasiexperimental study, supported by partnerships with older Canadians, advocacy organizations-Canadian Gerontological Nurses Association -gerontological nurses, and academic gerontological experts, will examine the effectiveness of e-learning activities on ageist attitudes then develop and implement strategies to combat such attitudes. --- Innovative learning approaches In Phase one of this project, we will use innovative methods such as e-learning-education delivered on a digital device [50]-that incorporates gamification, videos, and simulation to convey positive perceptions of older people and non-ageist behaviours by healthcare professionals. A systematic review of the literature [51] found that that e-learning is an effective strategy for improving professionals' knowledge, competence, and behaviours. Further, our literature review of web-based learning for nursing education revealed that gamification, simulation, and web-based virtual worlds are avenues that improve knowledge transfer and satisfaction with e-learning [52]. Gamification is defined as "the use of game design elements in non-game contexts" [53] p. 9 and is an engaging, interactive, and stimulating way to learn [54]. Nursing students identified that gamification increased their satisfaction with learning, stimulated creative thinking, and improved decision-making [55]. Virtual reality and self-directed e-learning, followed by practice in a virtual world, are also effective ways of acquiring new knowledge and skills [56][57][58][59]. Using e-learning activities to facilitate students' development of positive perceptions of aging and gerontological expertise does not require instructors with academic expertise in those domains. Such change opens the possibility of improved interactions and outcomes for older Canadians. Moreover, if e-learning is an effective method for student nurses, it may be effective with other healthcare professions as well. Phase I : dispelling stereotypes A quasi-experimental pre-post-test design will be used to test if the e-learning activities improve student nurses' perceptions about older people-in particular, by dispelling stereotypes and providing positive role models for working with older people. --- Setting and sample The study will be conducted at two Canadian nursing programs to provide geographic variability of eastern and western Canada . We estimate 1300 eligible students at York and 825 at U of C . Assuming a conservative 30% response rate, we anticipate a sample size of 640 students. The sample size is estimated to attain adequate power to detect a small effect size of the elearning intervention on student nurses' perceptions about older people. Using Cohen's [60] criteria of an anticipated small effect, a comparison among pre-and post-test scores and an α of .05 β set at .80, a minimum sample size of 393 is needed. To maximize the response rate, Dillman's [61] total survey method will be used. This method involves emailing eligible students a link to the e-learning activities and the survey. Non-responders will receive up to four email reminders, at two-week intervals after the first email . A $10.00 gift card will be offered as an incentive for participating in each learning activity; this has been identified to increase survey completion rates [62]. --- Learning activities To dispel negative stereotypes and ageism among student nurses, we will use three e-learning activities developed in our prior research [43] and previously tested with student nurses [63]. The topics of the activities were selected based on our prior work and target student nurses' most urgent gerontological learning needs [43]. We will use games, videos, and simulations that model positive behaviours in the e-learning activities to spark interest and capture participants' attention. Learning activity 1 will challenge negative stereotypes by providing information about healthy older Canadians and how to communicate with older people. Our previous research identified that student nurses lack knowledge about older people and how to communicate with them, which contributes to ageist perspectives [43]. We estimate participants will take 90 min to complete this activity. Learning activity 2 will focus on cognitive impairment , including positive modelling on how to manage anxiety and aggression in older people with these conditions. Previous research identified that student and practicing nurses do not feel equipped to work with older people with dementia [28,43,64,65]. We estimate participants will take 3 h to complete this activity. Learning activity 3 will focus on dispelling stereotypes about older people as dependent and incontinent. Continence is a complex health issue influenced by cognition and physical ability, including mobility [66,67]. Students nurses often hold negative stereotypes that incontinence is inevitable and believe it is not part of their job to help older people manage continence [68][69][70]. We estimate participants will take 90 min to complete this activity. --- Data collection Student nurses will complete a pre-and post-test using Burbank's [71] measure of their perceptions about working with older people and the Ambivalent Ageism Scale [4]; participants will also complete a post-test survey on their opinions of the learning activities. The preand post-e-learning activities will include the following three self-response scales: Burbank's Perceptions About Older People quiz [71] is a nine-item, 5-point Likert-type scale. The total score is derived by taking the mean of the responses. The higher the score out of five, the more positive the perception. This measure has demonstrated strong reliability and validity in previous studies [64,72]. The Ambivalent Ageism Scale is a 13-item, 7point Likert-type scale, which measures benevolent and hostile attitudes towards older people [4]. The AAS provides a means to examine the complexity of ageism, including both positive and negative stereotypes measured by the benevolent and hostile ageism subscales, respectively. The subscale scores are derived by taking the mean of the responses. The overall scale has high test-retest reliability and internal consistency . The reliability for the two subscales also demonstrated high test-retest reliability with benevolent , hostile and internal consistency for the benevolent and hostile subscales . Post-learning activity survey will be completed after each learning activity. The survey will include demographic questions and 5-point, Likert-type scale items measuring their perceptions about the learning activity. To control for possible order effects in the survey responses, the sequence of the e-learning activities will be randomized using a computer-generated randomization scheme. --- Data analysis Descriptive statistics will be used to describe participants' average standing on all measured variables. We will use paired t-tests to compare participants' pre-and post-test scores on Burbank's quiz and the AAS subscales. Phase II : developing anti-ageism strategies Our advisory group will include older Canadians, representatives from CanAge, HelpAge, and the CGNA, as well as gerontological experts. With help from our partners CGNA, AgeWell and CanAge, we will recruit older Canadians who represent rural and urban populations from different provinces. Through Appreciative Inquiry, which emphasizes positive change, the advisory group will examine the findings from the test case of student nurses' e-learning activity [73]. The findings from the test case of student nurses will promote discussion of the possibilities of using similar strategies with other healthcare professional groups or other populations. In bi-monthly virtual meetings over the 36 months of the project, group members will discuss where ageism is prevalent in the world around us. Through the meetings and examination of the test data, group members will reflect on ageism in Canada to develop short-, medium-, and long-term strategies aimed at dispelling ageism among professional groups that work with older Canadians, as well as the Canadian public. Anticipated outcomes include open conversations about ageism in our society and how it affects services delivered by Canadian health and social agencies. Four steps characterize the Appreciative Inquiry approach [73] we will employ: 1. "Discovering the core issues" will occur in the first 8 months and will include examining the findings from the test case of the e-learning activities with student nurses, as well as conducting group conversations about what participants in the advisory group view as salient issues. 2. "Dreaming about what might be" will occur from the 9th to 16th month, and will include gathering the advisory group's vision for an ideal future-when ageism is recognized, and stereotypes are dispelled. 3. "Designing strategies that facilitate a preferred future" will occur from the 17th to 26th month. The advisory group will develop short-, mediumand long-term strategies to facilitate positive perspectives and approaches to ageing and older people among professional groups and the Canadian public . 4. "A plan to implement the strategies" will be incorporated in the final phase of the project that will involve the advisory group developing and implementing the short-term strategies. The fourth step of Appreciative Inquiry aligns with our final objective, and thus constitutes final part of the research project. --- Our partnership approach A partnership approach is integral for this project because it brings together a diverse group of older Canadians, leaders from CGNA, AgeWell and CanAge, organizations that advocate for older Canadians, and academic gerontological experts to engage in an interdisciplinary, cross-sector initiative. The makeup of this partnership will ensure that the strategies developed are situated within the norms and practices of end-users. Our approach also provides opportunities to engage older Canadians and develop partnerships that may facilitate future research. It is only with this diversity that we can develop effective short-, medium-, and long-term strategies aimed at dispelling ageism in Canada. This partnership is needed to evaluate whether the data from the test of e-learning activities with student nurses is appropriate for use in dispelling negative stereotypes about aging with other professionals and the Canadian public, and can be used to generate other possibilities for developing strategies aimed at dispelling ageism. Importantly, the partnership provides the opportunity for researchers to learn from older Canadians as well as the leaders of organizations that advocate for and support older Canadians. Moreover, the partnership mobilizes a wealth of research knowledge from the academic gerontological experts. The partners' and academic gerontological experts' existing networks and contacts will facilitate knowledge mobilization, and we anticipate that future research flowing from this project will be enriched by the advisory group's partnerships and discussions. --- Knowledge mobilization Our advisory group will develop short-, medium-, and long-term strategies designed to dispel ageism. The short-term strategies will be implemented as part of this project. Working collectively will foster relationships among the partner organizations and academic gerontological experts to facilitate the mobilization of the short-term strategies, as well as enabling future partnerships to mobilize the medium-and long-term strategies . Knowledge mobilization will occur in the third year of the project, as the first two years will be occupied with identifying the issues, examining the data from the test of the student nurses' e-learning activities, and developing the strategies themselves. We will be guided by the advisory group to identify the most relevant short-term strategies and ensure that messages used to dispel ageism and the findings from the e-learning activities are widely shared with professional groups that work with older people, as well as Canadians more broadly. Avenues we expect to pursue include development of a website to host publications, infographics, podcasts, publications, and game-based e-learning activities emerging from this study, which will be accessible to all Canadians; publications in The Conversation Canada, a website that publishes academic stories for a lay audience; development of podcasts showcasing stories about older people and describing their experiences with age discrimination; targeting relevant media, such as radio and tv, with accounts that highlight ageism in Canada; and, using Twitter and Facebook to send messages aimed at dispelling ageism. We will create an animated narrative vignette of one of our final advisory meetings to disseminate messages to audiences such as older people, the general public, or school-age children. We will also use game-based approaches, which are effective in creating opportunities for anti-ageism messages that focus on specific target populations [74,75] to target professional groups and school-aged children to dispel myths about aging, and public talks by partners and academic gerontological experts summarizing our findings and the importance of dispelling ageism at venues such as community centres and at organizations like the Society for Aging in Greater Edmonton and the Canadian Association of Retired People . We will also link the project website to those of CanAge, HelpAge and CGNA to facilitate distribution of the study findings and implementation strategies to their members through their website, certification programs, and presentations at their biannual conferences. Notably, academics, nurse educators, and stakeholders in health and social agencies all attend CGNA conferences. The Canadian Gerontology Association includes health and social professionals and holds an annual conference to examine research related to ageing, which gives us the opportunity to disseminate information about our elearning results and anti-ageism messages. Additionally, our academic gerontological experts will collaborate to develop policy briefs to inform the Minster of Education and Canadian Association of Schools of Nursing of our findings and strategies needed to dispel ageism in schools across Canada. --- Discussion Ageist stereotypes and discrimination are pervasive in Canadian Society and undermine the health and wellbeing of older people. To address this issue, this project will raise awareness of ageism in Canada and challenge ageist stereotypes and practices in nursing, other healthcare professions, and the public. In this protocol, we have summarized our objectives, theoretical and methodological approach, and knowledge mobilization plan. The findings will have direct relevance to nursing programs across Canada, continuing education initiatives for practicing nurses, as well as anti-ageism education for other groups of healthcare professionals and the public. Student nurses will learn to challenge, rather than perpetuate, negative myths about ageing and will acquire urgently needed gerontological competence. Student nurses will learn to avoid unconsciously re-articulating ageist beliefs or behaviours in their nursing care. They will develop more positive perceptions of older people, as well as accurate knowledge of aging and common challenges faced by this population. The Canadian Association of Schools of Nursing and the Canadian Ministry of Education will be engaged in knowledge mobilization strategies with their members based on the findings. Moreover, our academic gerontological experts represent universities across Canada and are well situated within those organizations to disseminate the findings. We will work closely with nursing faculties to develop their expertise and understanding of gerontological competencies through the e-learning activities. The result will be improved experiences in healthcare settings and better health outcomes for older Canadians. Project partners-AgeWell, CanAge, and CGNA-will all benefit from participating in an interdisciplinary, cross-sector project. Their participation in the advisory group will enhance their understanding of the prevalence of ageism in student nurses as well as effective strategies to dispel negative stereotypes of aging in other professionals that work with older people and the Canadian public. This understanding will improve the care that health professionals provide to older people. The CGNA will have access to cutting-edge e-learning activities to better equip their membership with accurate information about ageist practices of older people they must be aware of and push against when service as clinical preceptors for undergraduate nursing students within their practice settings. This will help the CGNA to dispel ageist views and promote anti-ageist competencies and advocacy, as aligned with their national standards, which will ultimately positively affect older Canadians. The academic gerontological experts will also benefit from collaborating with one another, the partners, and older Canadians, and have opportunities to develop new research partnerships. The experts will learn from one another's unique programs of research and research experience, and new partnerships among leading scholars from across Canada will be forged. Finally, at the broadest level, our partnerships will facilitate ongoing work in dispelling Canadians' negative stereotypes of aging. Since older people represent the majority of the public, they will benefit from improved understandings about aging across the population as a whole, as well as from improved outcomes due to better service and care. Strategies to dispel negative stereotypes in the Canadian public will be developed, along with an implementation plan to guide their application. Public discourse catalyzed by our knowledge mobilization strategies, such as podcasts about how negative perceptions about aging affect older people, will open doors to frank conversations about ageist perceptions and practices within Canadian society. The messages that the advisory group develops to dispel ageism will further support honest and transparent public conversation, which we anticipate will move Canadians forward in eliminating ageist practices. --- Abbreviations AAS: Ambivalent Ageism Scale; CARP: Canadian Association of Retired People; CAG: The Canadian Gerontology Association; CGNA: Canadian Gerontological Nursing Association; SAGE: Society for Aging in Greater Edmonton Authors' contributions SD and KFH conceptualized the research project. SD, KFH, MF and SJD analyzed the data that contributed to the development of the e-learning activities. SD wrote the grant application with input from all and JIB drafted the manuscript based on the grant. MTF contributed to the quantitative components of the grant and manuscript. KFH, MTF, SD, CR, AC, LSM, NP, LTW, VB, LM, EM contributed edits and refinement to the manuscript. The author read and approved the final manuscript. --- --- --- --- --- Competing interests The authors declare that they have no competing interests. ---

Background: Making fun of growing older is considered socially acceptable, yet ageist humour reinforces negative stereotypes that growing old is linked with physical and mental deterioration, dependence, and less social value. Such stereotypes and discrimination affect the wellbeing of older people, the largest demographic of Canadians. While ageism extends throughout professions and social institutions, we expect nurses-the largest and most trusted group of healthcare professionals-to provide non-ageist care to older people. Unfortunately, nurses working with older people often embrace ageist beliefs and nursing education programs do not address sufficient anti-ageism content despite gerontological nursing standards and competencies. Methods: To raise awareness of ageism in Canada, this quasi-experimental study will be supported by partnerships between older Canadians, advocacy organizations, and academic gerontological experts which will serve as an advisory group. The study, guided by social learning theory, will unfold in two parts. In Phase 1, we will use student nurses as a test case to determine if negative stereotypes and ageist perceptions can be addressed through three innovative e-learning activities. The activities employ gamification, videos, and simulations to: (1) provide accurate general information about older people, (2) model management of responsive behaviours in older people with cognitive impairment, and (3) dispel negative stereotypes about older people as dependent and incontinent. In Phase 2, the test case findings will be shared with the advisory group to develop a range of knowledge mobilization strategies to dispel ageism among healthcare professionals and the public. We will implement key short term strategies. Discussion: Findings will generate knowledge on the effectiveness of the e-learning activities in improving student nurses' perceptions about older people. The e-learning learning activities will help student nurses acquire muchneeded gerontological knowledge and skills. The strength of this project is in its plan to engage a wide array of stakeholders who will mobilize the phase I findings and advocate for positive perspectives and accurate knowledge about aging-older Canadians, partner organizations (Canadian Gerontological Nurses Association, CanAge, AgeWell), and gerontological experts.

Background Periodic menstrual bleeding is an integral component of the human female reproductive cycle, [1] but the way this phenomenon is viewed and the meanings attached to it vary considerably in different societies around the world [2][3][4][5]. Most cultures require that menstrual flow be regulated or contained in some fashion. This cultural requirement creates a recurrent challenge to all menstruating girls and women. These menstrual management challenges are often most acute at menarche, because newly-menstruating adolescent girls often lack the knowledge, experience, and self-confidence necessary to deal with the problems of menstrual hygiene [5][6][7][8][9][10][11][12][13][14][15]. Factors that influence menstrual hygiene management include knowledge of reproductive biology; the background beliefs about menstruation prevalent in society; the limitations that beliefs about menstruation place on female activities; and the ease of access that girls and women have to menstrual management supplies such as commercially-manufactured sanitary pads , tampons, or traditional menstrual management materials obtained from the home environment such as strips of cloth torn from old bedding, skirts, shawls, or other articles of clothing. Particularly in low-income countries, menstrual hygiene management may present a formidable obstacle to the education and social advancement of adolescent girls, who are often confused, embarrassed, and unprepared for the sudden and unexpected appearance of menstruation [12][13][14][15][16][17][18][19][20]. The Dignity Period Project is a collaborative community development project between Mekelle University , the Mariam Seba Sanitary Products Factory , and Dignity Period which seeks to improve knowledge about menstruation in northern Ethiopia and to provide free, locally-produced, environmentally friendly, reusable menstrual hygiene products to schoolgirls in this region. The project hopes to improve the psychosocial environment of Ethiopian girls with respect to menstruation, to reduce school absences from menstruation-related causes, and to stimulate the growth of a viable commercial industry that someday can meet the need for menstrual hygiene supplies in an efficient, locally-sourced, and cost-effective manner. The project provides educational materials about menstruation to girls and boys in Ethiopian schools through a bilingual educational booklet [21] and on-site, in-school training on menstrual hygiene management. The project also provides schoolgirls with free menstrual hygiene kits containing 2 pairs of underwear and 4 washable, reusable menstrual pads [Fig. 1]. By the end of 2018, the project will have reached over 250,000 students in Tigray and in the contiguous Afar Region of Ethiopia. The present study is part of ongoing efforts to understand menstruation and menstrual hygiene in this part of the country. --- Methods An ethnographic survey of menstrual beliefs in Tigray, northern Ethiopia, was carried out through focus groups, in-depth interviews, and individual case studies in conjunction with a previously-published communitybased survey of this topic [22]. There were 40 focus group discussions, 64 in-depth interviews with key informants, and 16 individual case histories. A total of 322 individuals participated, including 240 people in six different types of focus groups: pre-menarchal girls , menstruating adolescents , mature married women of reproductive age , post-menopausal women , adolescent males , and mature married men . In-depth interviews were also carried out with 80 individuals, including Orthodox Christian priests , imams from the Muslim community , secondary school principals , teachers and nurses , as well as menstruating schoolgirls . Focus groups were run by native speakers of the local language , except in the Tahtay Adyabo subdistrict, where indigenous speakers of Kunamigna were used as translators for this ethnic group. The sessions were recorded, transcribed, and then translated into English. Audio data were transcribed and translated, then broken down into discrete codes using Atlas Ti software and grouped into related families and sub-families based on their content. The results were synthesized by themes to construct a narrative concerning menstruation in Tigray. The study protocol was reviewed and approved by the institutional review boards at Ayder Comprehensive Specialist Hospital, College of Health Sciences, Mekelle University, Mekelle, Ethiopia, and by the Washington University School of Medicine in St. Louis, MO, USA. Informed consent was obtained prior to each interview or focus group discussion. Study subjects were compensated for their time and participation with 50 Ethiopian Birr . Fig. 1 Menstrual hygiene kit distributed by the Dignity Period Project, consisting of 2 pairs of underwear and 4 re-usable menstrual pads. The pads have a waterproof backing; a soft, cotton absorbent lining; and they fasten over the crotch of a pair of underwear using a button. The pads are cleaned by soaking in water, hand-washing with soap, rinsing, and then air-drying in the sun. Ultraviolet radiation from direct sunlight has a bacteriocidal/bacteriostatic effect. Photo by the authors --- Results A number of recurrent themes emerged in the course of these interviews and focus-groups. We have organized these themes into four broad categories for the purpose of discussion: the nature and biological function of menstruation; menarche; menstrual restrictions; and menstrual needs, hygiene accidents, and associated stigma. --- The nature and biological function of menstruation There is universal agreement that menstruation is a normal physiological process linked to reproduction. Most people refer to it as a "gift from God" which permits women to become pregnant and bear children, to give the gift of new life, to become mothers. As one woman said, "It means the body is ready to reproduce." Only the most educated members of our participant population could provide a reasonably accurate description of the biology of conception and its relationship to menstruation. A typical approximation of these responses was given by one male who noted "menstrual blood is part of life and the process of making life. It becomes blood if it is not fertilized"-a recognition that menstruation regularly follows when fertilization does not occur. It is generally understood that menstruation stops during pregnancy. Menstrual periods are described as occurring monthly with some variability, and bleeding is said to last for roughly 3-7 days. Periods of longer duration or more unpredictable occurrence are regarded as potential reasons to seek medical advice. There is good awareness that certain contraceptive technologies can cause changes in the menstrual cycle. There is also a recognition that menstruation ceases when menopause occurs . At menopause the potential for becoming pregnant also ceases. The phenomenon of menstruation has different names in different Ethiopian languages. Menstruation is commonly called the "monthly flower" . As one Orthodox Christian priest explained it: "Menstruation is like flowers. Flowering plants finally produce fruit. The same is true of girls after menstruation." Another common expression for menstruation in Tigrigna is nay adetatna , which also links it clearly to reproduction. In the Kunamigna language menstruation is called mara or ginayaka . Among the Raya people and others it is often called adef . As discussed below, menstruation is commonly regarded as ritually polluting. Many women also believe that it is a cleansing process. One menopausal woman remarked "the blood that comes during menstruation is bad blood and after bleeding the woman makes good blood." Another woman said "It releases bad blood out of our body; it cleanses the system." Still another woman remarked "It voids useless fluids from your body." The notion that loss of menstrual blood cleanses or purges the body is common in many other cultures [2,3]. --- Menarche Males and females both agree that menstruation occurs for the first time in adolescence and that it heralds the onset of female reproductive capacity like the first "blossoming of a flower." There is a widely held consensus that the timing of the onset of menstruation varies depending on the girl's constitution and her living conditions: in the view of many people, good health and good nutrition are linked to an earlier occurrence of menarche. There is also a common, but not universal, belief that menstruation does not start until a girl has sexual intercourse for the first time. The existence of this false belief presents a potential hazard for girls approaching menarche if they live in families where this belief is held. We know of some girls who have been beaten by their fathers at menarche because they were assumed to be sexually active and misbehaving, when, in fact, they were merely bewildered adolescents having their first menstrual periods. The emotional scars of such experiences are likely to be deep and long-lasting. This belief also may result in some schoolgirls being disparaged by boys as having lost their virginity if they suffer a hygiene accident at school that results in their menstrual status becoming known. Many Tigrignan girls enter adolescence with little or no knowledge of menstruation. Their first periods are often unexpected, traumatic experiences, as several participants described. "It [menarche] happened to me when I was going back to my house from a test I had taken in the eighth grade. I had not been feeling well during the day. In the middle of the road I started to bleed and I was scared. I used a piece of cloth and put it in my underwear. Nobody saw me; but I was very worried and frightened. I didn't tell my parents." Another girl said "I went to school and while I was learning suddenly the blood was visible through my uniform. I was shocked and embarrassed. I covered up my uniform with my school bag and went home. I didn't tell my mother what happened and I immediately went to my room so as not to be seen." An older woman remarked: "I was in school when I first had my period. When I felt it, I thought that it was urine and I had to go to the bathroom. When I went to the bathroom, I felt the blood. I had no underwear. I had to use the inside of my skirt and wrap it around my body. Then I went back to class and sat on my exercise book. I managed to avoid getting my dress soaked in blood by keeping it away from the blood. I had to wait until all of the other students were gone before I stood up and left the classroom. Then I went to my house and didn't talk to my parents or siblings. In the meantime, I had to steal my older sister's underwear and use it. I used dirty, worn-out clothes that were not useful for other purposes. Finally, I told my friend about it. She was my schoolmate. She spoke with our teacher and they bought me underwear and a pad." Stories of this kind are common. --- Menstrual restrictions Numerous cultural restrictions are imposed during menstruation in Tigray. Although girls and women are expected to continue their normal household chores while menstruating, there is a general belief that menstruants are vulnerable and should not do heavy physical labor while on their periods. Hard physical work is thought to increase the bleeding. One woman explained "A woman's womb is open during menstruation and if you load yourself with a heavy load, it can cause a problem and too much bleeding." The underlying belief appears to be that the uterus is like a sack full of blood and if you strain, more blood comes out. Women probably do notice an increase in bleeding with straining or lifting, particularly if they lack underwear or effective sanitary pads to contain the menstrual flow. On the other hand, there is also the pragmatic realization that the daily work of the household must get done irrespective of what else is happening. For poor women in particular, there is no alternative but to do the work themselves. Economic necessity overrides personal preferences. Many informants expressed the belief that menstruating women should avoid exposure to direct sunlight. There is a prevalent belief that if a menstruating woman is out in direct sunlight she will develop a debilitating and potentially serious medical condition called michi. Thus, to the ritually polluting nature of menstruation is added the belief that being "out" risks serious health consequences to the woman herself-a belief that also keeps the subject of menstruation "in the shadows," both figuratively and literally. A more common concern than the development of michi, however, is the presence of menstrual cramps and how to manage them. Dysmenorrhea is often cited as a reason that menstruating girls do not attend school. School absences are also increased if they have difficulty accessing adequate menstrual hygiene supplies. Acetominophen is frequently used as a treatment for cramps, but it is not always readily available in schools and access to more effective non-steroidal anti-inflammatory drugs such as ibuprofen or naproxen is almost non-existent. Many girls report trying to manage menstrual cramping by taking hot drinks, applying hot water bottles, or resorting to traditional folk-remedies such as rubbing the abdomen with butter to soothe the cramping. Lack of access to effective pain medications for menstrual cramps while at school was cited as a common problem that adversely impacted school attendance and learning. The intake of certain foods and fluids is thought by many to influence menstrual flow, but these beliefs are inconsistent and often contradictory, reflecting an uncertain understanding how they might work. . Many people say menstruating girls should take hot drinks while menstruating, perhaps for their soothing qualities; but others deny this and say that hot drinks only serve to increase the amount of menstrual flow and that menstruants should take only cooling drinks instead. In many cultures there is a belief that "cooling" the blood leads to clot formation and sluggish menstrual flow, whereas heat is thought to increase menstrual circulation [2]. Something conceptually similar to this may be in play here. Most respondents believe that women should take "good" food and stated that girls and women should avoid overwork while menstruating in order to conserve their strength. Unlike some parts of the world, there do not appear to be restrictions in Tigray on the ability of menstruating women to prepare food . Only one or two men said they would prefer not to eat food cooked by a menstruating woman. A more typical response was offered by one Orthodox priest , who, when asked whether or not he would eat food cooked by his wife if she was menstruating, said somewhat incredulously: "Well, who else would prepare it for me?" Cooking is a responsibility that women are expected to assume in the household and this is not abrogated by menstruation. Nonetheless, menstruation is foreign to male physiological experience and is not usually discussed openly. There is a general male wariness about menstrual blood. Many informants reported that diseases could be transmitted through menstrual blood . One said: "If women don't dispose of hygienic materials properly and if it touches body parts that may be sensitive to disease, it may cause disease." Such beliefs about the potential infectiousness of blood have likely been increased by HIV/AIDS awareness campaigns in Ethiopia. When asked if it was permissible to have sexual relations with a woman while she was menstruating, there was generally strong disapproval of this practice by both males and females. Although some people believed that such intercourse would result in pregnancy, almost all respondents voiced cultural, religious, and aesthetic disapproval of having intercourse with a menstruating woman. One woman explicitly likened this to incest. Referring to menstruation as "[the thing] of our mothers," she said "If a man sleeps with his wife when she is on her menstrual period it is like he was sleeping with his mother,"--a very strong aversion indeed! Orthodox priests and Muslim imams both said that sex was not permitted during menses. "I won't have sex with a menstruating girl," one young man reported, "because her blood may contaminate me." Another young man said "It is forbidden to have sex with a menstruating girl in our tradition. Besides this," he added, "girls smell bad during their menstrual periods." A specific aesthetic objection was thereby added to the general cultural disapproval of this practice. There is a strong cultural tradition among both Orthodox Christians and Muslims that menstruating girls and women are ritually impure and should be excluded from religious activities. Menstruants are prohibited from entering the mosque or the church; rather, they should remain outside and pray by themselves. This largely appears to be a self-imposed restriction, however; we are not aware of any attempts to check the menstrual status of women at sites of religious worship. As such, a girl's menstrual status is a matter between her and God, but many people seem to feel that God Himself would be personally offended by a menstruating girl or woman who comes into His holy presence. One pre-menarchal girl declared with certainty: "She [a menstruating girl] can't fast or pray in a church for it is useless and not accepted by God." Many people also expressed the belief that menstruants should not touch sacred objects such as the Bible, a cross, holy water, or the Koran. Such beliefs about menstruation and ritual pollution put women at a serious disadvantage in a society where religious influences remain very strong and permeate many aspects of the culture. --- Hygiene needs, menstrual pads, and menstrual stigma How to manage menstrual hygiene is an omnipresent concern for females, particularly for poor girls and women in rural areas where living standards may be often marginal. The embarrassment and shame that result from a public menstrual hygiene accident can be overwhelming for the girl who experiences it, particularly during her vulnerable early adolescent years. We heard many reports of schoolgirls who were taunted by boys who ran after them, shouting and making fun of them if they had visible menstrual staining on their clothes at school. The mortification that results from such public shaming can be severe. One girl reported an incident in her school in which a very bright female student was called to the front of the classroom to write on the blackboard only to realize that the entire class was staring at her backside. To her horror she discovered that the seat of her dress was soaked in menstrual blood. She was so ashamed that she left the classroom immediately and decided to change schools rather than return to the scene of her humiliation. Other girls who have experienced such accidents stop coming to school while on their periods; some simply drop out altogether. One older woman reported concerning her own girlhood: It was difficult back in the day [when you were on your period.] You sat down and stayed in one place. If you were making coffee [a common and important Ethiopian social ritual for guests], you would prepare everything but not move at all. You would be careful not to get blood on your dress. You just covered yourself and were self-conscious. You would be especially careful if there was a guest or a boy who might see you. Another woman said: "Back then there were no things like underwear and sanitary pads. I lived in a village and we didn't know about it. It was very difficult to socialize without having underwear. It was common to miss two or three days [of school each month]. I used to miss class. I menstruated at 15 or 16 but there was no underwear or sanitary pads. We wore traditional [white] dresses and it was not easy to control menstruation. We were farmers. If I was seen bleeding in class the students would make fun of me." The rest of her focus group chimed in with enthusiastic support, shouting "That is it! She has said it!" Her comments touched a "social nerve" that was felt by all the women present. Many teachers reported that poor girls routinely skipped class during their menstrual periods for fear of being publicly exposed to such shaming. One adolescent boy remarked, "I don't think girls ever stand up without looking at their seats because they know what will happen if students see blood." One adolescent schoolgirl said "At school there is not any kind of support [for menstruation]. If we bleed, we have to go home because we have financial problems [and cannot afford to buy menstrual pads]." The fear of exposure of their menstruating state due to an accident of hygiene is constantly on the minds of girls and keeps them from concentrating on their lessons. One informant said, "A menstruating girl is afraid to go to school and when in class she cannot pay attention due to fear of menstrual staining." Another girl said, poignantly, "My menstrual pad fell out while I was playing football [soccer] at school. All the students laughed at me and shouted at me and I missed school for three days." The stress of participating in required vigorous physical activity while trying to wear a menstrual pad with no underwear to support it was extremely stressful and several women reported similar incidents in their lives. One of the most common obstacles to school attendance is lack of adequate menstrual hygiene supplies. Commercially produced, disposable pads are often not accessible, but even when they are available, they are too expensive for poor rural woman to buy. Proper disposal of such pads is also problematic. The price of a package of disposable menstrual pads was stated as 18-25 Birr per month, but as several women stated, "It is very expensive. We are poor" and "For a poor woman, it's difficult even to afford one pair of underwear." One woman remarked, "It's expensive, let alone 18 Birr! Even 8 Birr [$US 0.35] is expensive!" Another said, "Some can't even afford three or four Birr" [~$US 0.18]. A Muslim iman with a large family lamented, "They cost 18 Birr-if you have three daughters it will be especially difficult." For him, menstruation was a familial financial catastrophe. The alternative to using commercially-produced sanitary pads is to make do with strips of cloth torn from old dresses, pieces of old mattresses, or whatever absorbent materials may be at hand, but such remedies are often not effective. As one teacher summarized the problem, "Most of the girls do not attend class [when they are menstruating] since they don't have menstrual pads or even clean pieces of cloth." There is a general consensus that good hygiene is important. The most common view is that girls and women should wash themselves several times per day when they are menstruating and that this is particularly important if they don't have menstrual pads; but scarcity of water is a constant, pervasive problem throughout Tigray, particularly in schools. Women in rural areas may have to carry water several miles from the nearest water-source in order to have a supply at home, which makes water a precious household commodity. Lack of water for washing is very common, particularly in rural schools. Many schools have no source of running water on site and the only water available is whatever students can carry from home in containers for their daily use. There is also a belief that washing or bathing during menstruation increases the flow of blood. In the past, many girls were actually forbidden to wash while menstruating, which undoubtedly only increased their discomfort. These beliefs may be intertwined with one another. There was general agreement that schools should furnish menstrual pads to girls and that schools should also have medications for menstrual cramps available for student use. Both strategies were felt to be beneficial for improving school attendance. There was also general agreement that toilet facilities at schools were inadequate-especially for girls---and needed much improvement. This is readily demonstrable in almost any school in the region [Fig. 2]. There was agreement that girls' toilets should be well separated from those used by males to ensure better privacy, especially when dealing with intimate issues such as washing and changing menstrual pads during the day. When asked in a focus group discussion what should be provided in school latrines, one woman stated forcefully: "I would build a latrine with a shower and toilet inside. I would have well-made menstrual pads and soap! And it would have a continuous supply of water and soap!" [much laughter and cheering from the group]. Achieving this ideal seemed hopelessly remote, given the local economic circumstances, but nonetheless such improvements were greatly desired, and it was thought that such facilities would contribute substantially to improved gender equity in the Tigray Region. --- Discussion: Menstrual hygiene Management in Context In recent years menarche and menstruation increasingly have become recognized as important public health issues with particular salience for the health and psychosocial well-being of adolescent girls [13-16, 20, 22-24]. The increasing attention paid to these issues has produced several qualitative studies from East Africa which document the impact that lack of adequate resources for coping with menstrual hygiene has on adolescent girls [6,12,19,[22][23][24][25][26][27][28][29][30][31][32][33][34]. Menstrual hygiene management is difficult and inadequate throughout Ethiopia . Our study confirms and enlarges the qualitative research on menstruation, with specific reference to northern Ethiopia. The challenges Tigrayan schoolgirls face in managing their menses is rooted in a general cultural reluctance to discuss the subject of menstruation, a problem which is Fig. 2 Typically inadequate toilet facilities at a secondary school in rural Tigray. Photo by the authors made worse by inadequate scientific education concerning sexuality and human reproductive biology. The failure to discuss menstruation at home means that many girls arrive at menarche unprepared for the experience of menstruation. This phenomenon is certainly not limited to Tigray [4-20, 30, 31]. When their menstrual bleeding first begins-often unexpectedly-girls may be frightened, embarrassed, and suffer unnecessary psycho-social trauma. Some people in this region believe that menstruation does not begin until a girl has sexual relations [22], which may precipitate unfounded, scurrilous rumors about sexual misbehavior and provoke baseless family conflict. Not knowing what is really happening during their menses, many girls are worried, fearful, and go to great lengths to hide their bleeding from others, especially from family members. For these girls, containing the menstrual flow is a major, anxiety-ridden preoccupation while they are on their periods. This task is made more difficult by lack of access to satisfactory menstrual management materials, which are either unavailable, too expensive, or have inadequate absorbent capacity. Male family members who control financial resources often do not understand the importance of this aspect of their daughters' lives because of ignorance or benign neglect [35]. The resultant anxiety over possible menstrual hygiene accidents at school or elsewhere in public is often so high that girls stay home while menstruating and fall behind in their studies. The stigma associated with menstruation is increased by negative religious attitudes that categorize menstruating women as ritually unclean, as well as by thoughtless, mean, and sometimes cruel taunting and teasing behavior by fellow students when menstrual hygiene accidents occur. The school environment is perceived as difficult for menstruating girls due to the social pressures surrounding this normal physiological process, and this is worsened by pitifully inadequate toileting facilities, poorly constructed latrines, lack of access to soap and water for cleaning, lack of menstrual pads when menstruation begins unexpectedly, and lack of basic medications to help with menstrual cramps when these occur. Our findings from Tigray confirm the presence in that region of the problems so commonly reported elsewhere [36]. The Kenyan comment that "the girl with her period is the one to hang her head" [6] applies equally to the Tigray Region of northern Ethiopia. We have not, however, found evidence thus far that Tigrayan girls trade sexual favors for access to menstrual hygiene supplies as has been reported in Kenya [29]. This should be a topic for further investigation. Meeting the challenges surrounding menstrual hygiene requires a multilateral approach. There is a great need for better instruction in the science of human reproductive biology, including the female hormonal cycle and how it relates to fertility and menstruation. A strong understanding of basic human reproductive biology would go far towards creating a more compassionate attitude towards menstruation. Cultural attitudes towards menstruation in Tigray are strongly influenced by religious perspectives on menstruation that developed centuries before the science underlying the female reproductive cycle was understood. A broader understanding of the biology of menstruation throughout the general population could open the way for more nuanced theological discussions of this and related topics. In addition, there is a great need for improving the physical environment of Tigrayan schools, especially as it relates to hygiene. In many places latrines are substandard, even unsafe . Boys' latrines should be segregated from girls' latrines and there should be enough room and enough privacy within girls' latrines to allow easy changing of menstrual pads and attention to basic washing and cleaning [36]. The provision of fresh water is a particular challenge in Tigray, where drought is common and on-site water sources often do not exist. Each school should make sure that it has an acceptable, functioning gender office which can supply sanitary pads on an emergency basis, basic medication for the relief of menstrual cramps, and a place for girls to rest if necessary. The Tigray Regional Educational Bureau is taking steps to make this happen. By itself, improved education about menstruation appears to have a positive impact on menstrually-related absences by adolescent schoolgirls [37]. It seems likely that provision of menstrual hygiene supplies to students also has a positive impact on school attendance by girls, although further research in this area is needed to solidify this perception [37][38][39]. In light of the fact that menstruation is an unavoidable experience for girls in low-resource countries, effective programs to lower the barrier this presents to school attendance and their further education is highly desirable. Strong evidence demonstrates that further education improves health and family outcomes, lowers child mortality, and produces positive economic benefits [40,41]. These are all valuable public policy goals. A recalibration of school and community values to make menstrual hygiene a higher priority than it is at present will be necessary to bring this about. --- Conclusion Changes in the educational system are required to improve the understanding of menstruation by all students, male and female, to foster gender equity and to create a society more understanding and accepting of menstruation. --- --- Authors' contributions LLW: Protocol/project development; data management; data analysis; manuscript writing/editing. KT: Data management; data analysis; manuscript writing/editing. AD: Data management; data analysis; manuscript writing/editing. SB: Protocol/ project development; data collection and management; data analysis; manuscript writing/editing. All authors have read and approved the final manuscript. --- --- Consent for publication Not applicable. Competing interests L. Lewis Wall serves as a non-compensated member of the board of directors of the charity, Dignity Period. The other authors have nothing to declare. ---

Background: Menstruation is a universal aspect of human female reproductive life. Management of menstrual flow presents hygiene challenges to girls and women in low-income countries, especially when they first start their periods. As part of a project to improve menstrual hygiene management in the Tigray Region of Ethiopia, we explored the local understanding of menstruation through focus-group discussions and individual interviews. Methods: A detailed ethnographic survey of menstrual beliefs was carried out through 40 focus group discussions, 64 in-depth key informant interviews, and 16 individual case histories in the Tigray Region of northern Ethiopia. A total of 240 individuals participated in six types of focus groups (pre-menarchal girls, menstruating adolescents, married women of reproductive age, post-menopausal women, adolescent males, and married men). In-depth interviews were also carried out with 80 individuals, including Orthodox Christian priests, imams from the Muslim community, principals of primary and secondary schools, teachers and nurses, as well as menstruating schoolgirls and women. Audio data were transcribed and translated, then broken down into discrete codes using Atlas Ti software (version 7.5.4, Atlas.ti Scientific Software Development Mnbh, Berlin) and further grouped into related families and sub-families based on their content. The results were then synthesized to produce a cohesive narrative concerning menstruation in Tigray. Results: Recurrent themes identified by participants included descriptions of the biology of menstruation (which were sometimes fanciful); the general unpreparedness of girls for menarche; cultural restrictions imposed by menstruation on females (particularly the stigma of ritual uncleanliness in both Christian and Muslim religious traditions); the prevalence and challenges of unmet menstrual hygiene needs at schools (including lack of access to sanitary pads and the absence of acceptable toilet/washing facilities); and the stigma and shame associated with menstrual hygiene accidents in public. Conclusions: Changes in the educational system in northern Ethiopia are required to improve student understanding of the biology of menstruation, to foster gender equity, to overcome the barriers to school attendance presented by poor menstrual hygiene management, and to create a society that is more understanding and more accepting of menstruation.

Introduction The school, as a social institution, establishes, legitimises, and validates basic learning and ways of being that allow students to act according to the established standards, thereby becoming guarantors of the social order and a reproduction mechanism of the current system . Satisfactory results in evaluations and appropriate adaptation to institutional norms determine some classifications, such as those that categorise "good" and "bad" students. The first group is considered competent, responsible and autonomous; on the other hand, students who present different behaviours from what the school expects, who do not pass the year or who do not "adapt" to the institution's established profile are designated as "bad students" at risk of school failure . This conceptualisation is determined by the changes in the different educational systems that result from the historical moment, the culture, and the educational model in which an educational community is immersed. Being a "good" or a "bad" student depends greatly on the magnitude of difficulties that a pupil may encounter during their school years in adapting to the demands and evaluating gaze of each school . These situations are "the expression of how much, in educational terms, we still have to do" and lead to school being a possible obstacle to equality and inclusion, rejecting difference and demonstrating the limitations of the school to accommodate it . Describing the social representations that prevail in educational communities about students who are possibly at risk of failing at school and how these representations determine whether or not this actually occurs allows us to understand how these situations are configured and to identify the reality of the school and the knowledge that is produced, not only scientific knowledge but also everyday knowledge. Social or everyday knowledge is created in every social scenario-such as schools-through human interaction and includes symbolic, affective, and cognitive contents that in some way determine life, whether that be its forms of organisation or communication . Systems that are constructed recognise beliefs, stereotypes, opinions, classificatory logics, values, and norms, and they define a collective conscience that governs with normative force by establishing limits and possibilities in the way community members act. These systems are known as social representations, and they arise from the interconnected relations that are typical of interaction, in which each community member can accept, reject, or stigmatise other people through the construction of their own social representations. Undertaking studies into the representation of a subject leads to the recognition of the modes and processes that constitute social thought, through which people construct and are constructed by social reality. Therefore, it is essential to understand how social representations appear, how they produce knowledge from daily life and how they emerge in groups when discourse and communication suggest shared or divergent points of view and perceptions on various issues, situations, or people . Some studies carried out on the subject of school failure from the perspective of social representations in Spain examined parents, teachers and students' opinions on school failure. They then identified some internal causes and external causes . These studies have theorised about the impact that these representations can have on students and their schooling process, suggesting that failure leads to mistreatment that ends up justifying exclusionary and discriminatory educational practices, which in the long run lead to early school leaving, poor working conditions and low income, ultimately resulting in trigger poverty and social injustice. Other research carried out in Argentina by Federico Butti and María Paula Quiroga thematised the social representations that circulate concerning possible adolescent school trajectories in working class sectors of society in relation to school success or failure. Their ethnographic studies established the mediation of representations in social interactions and characterized the relationship between the students' social class, the timing of school hours , the location of the school, teachers' expectations, and parents' educational background as possible determinants of adolescent school failure. Finally, the research conducted by Zamudio Elizalde et al. in Mexico used questionnaires to analyse, from a quantitative perspective, which elements of the social representations of high school students have an impact on school failure. All this research has been taken as a key input in the development of this analysis. Therefore, this study represents the possibility to make an analysis of a school in Colombia, from the perspectives of different stakeholders and through their own voices and feelings, in order to answer the following: What are the processes that put "problematic students" at risk of school failure in an official educational institution in the city of Bogota, and how do they come about? What are the social representations that teachers, parents, and classmates have about these students? What type of institutional responses are there for this type of student? In this way, we will describe the social representations that predominate of students at possible risk of school failure in one educational community and determine if and how these representations determine the actual risk of failure occurring, as it is a phenomenon that continuously develops inside the school and can be approached from different perspectives within national, local and institutional environments. 1.1. Literature Review 1.1.1. School Failure: A Multicausal Reality School failure is a term that, at a general level, not only designates students who do not complete compulsory education , but also denominates, measures or quantifies a negatively charged reality by explaining it with "apparently depoliticised" figures, which end up being individualised within the school . Through various studies, it has been found that school failure is synonymous with students' disengagement with their learning , with the school and with their own grades . Hargreaves establishes differences between what he calls schools that fail and failure inside the school. For the first situation, he considers that it is necessary to carry out institutional change, which includes all members of the school community-principals, teachers, parents, and students-all of whom must recognise the situation and specific actions for improvement. As for failure inside the school, he considers it as a possible form of exclusion based on the idea of capabilities and individual conditions that separate and divide people: "those who have not succeeded, those who fail, become victims of distinction, the object of the displeasure and scorn of others" . In this way, a school that fails is considered an institutional problem, while failure inside school is an individual problem. For the OECD , school failure is an unfortunate consequence of inequity and exclusion due to the lack of opportunities, the most obvious example of which is school dropout. School failure is a term used in various realities: pupils with discordant behaviours, those with low academic achievement or those who skip or have dropped out of school, among others. It also assumes all failures are the same, building a subjectivity and image of these students as "failed subjects" who fail to make progress in different life areas. This assumption negatively affects students' confidence and self-esteem, focusing the problem on them and forgetting the responsibility of other actors such as the family, the state or the school . In other words, school failure is the result of an accumulation of misunderstandings, tensions, struggles and unfortunate experiences in various contexts, and something that requires us to look at the educational system and its relationships, rather than just at students . For this research, school failure is taken as a multicausal phenomenon and situation , which happens to some students who, once the school year or their time at school has finished, have not acquired the minimum knowledge, skills or abilities needed to pass the year. These students do not "adapt" to the standards, and their undesirable or unexpected behaviour does not fit within the boundaries set by the educational community . In search of a referential framework that provides access to the school space to understand the way in which this situation is configured from social knowledge that is built from and about the subjects that inhabit educational scenarios, social representations are presented as spaces of recognition that may contain a variety of situations such as school failure that, when crystallised through a word, a gesture or an encounter, allow for a much closer reading of any reality. --- Social Representations and the Construction of the School Reality Representations define a common frame of reference that allows social exchange, transmission, and dissemination of "spontaneous" and "innocent" knowledge. Representations make it possible to understand and explain reality, to acquire knowledge and to integrate it into a framework that is comprehensible to the individual . Moreover, representations bring us closer to the "world view" that people or groups have since this knowledge is used to act or take a position before other subjects based on language and communication that construct and give meaning and sense to reality . Addressing social representations makes it possible to understand the dynamics and the determinants of social interactions since representation, discourse and practice are mutually generated . This all underlines the importance of knowing, discovering, and debating their origin, from which a representation and therefore a social practice can be modified. Moscovici defines social representations as a system of values, ideas, and practices that, on the one hand, establishes the order with which individuals orient themselves in the social and material world and, on the other hand, enables communication by providing a code with which they classify the different aspects of reality and their individual and group history. Social representation is a construct that arises from the perception of and previous knowledge regarding a subject . In the same sense, Jodelet states that a social representation is socially elaborated and shared knowledge that helps to understand reality and give it a meaning and a sense; it is knowledge with a practical character in daily life, as it gives possibilities to accept or reject the other person, to know how to act in front of them and to assign them a place in society. Social representations concern the knowledge of common sense, which are available to be used in daily life experience; they are perceptions, constructions with the status of a naive theory, which serve as a guide for action and an instrument for reading reality, and systems of meanings that allow us to interpret the trajectory of events and social relations; they express the relationship that individuals and groups maintain with the world and other people. These representations are forged in interaction and contact with the discourses that circulate in the public space; they are inscribed in language and practices, and they work as a language because of their symbolic function and the frameworks they provide to codify and categorize what makes up the universe of life. This approach combines cognitive and social dimensions oriented towards the communication and understanding of the social environment and reality as a process to create this "common sense" knowledge. Determining how a community member constructs a representation of a pupil in a possible school failure situation implies knowing the dynamics and factors that influence this construction through community perceptions and experiences. Thus, a social representation is consolidated as the interpretation made by a community about a studen, from dimensions such as information, attitude, and the field of the representation that is built . As it is not possible to separate a representation from the everyday practices that are inherent to it, when we study representations, we first look at the contents and processes of social learning about the object of the representation as a collective construction. Representations give a deeper insight into the knowledge mechanisms to understand what is at the basis of human actions, they facilitate perception and action in the face of an external variable or unknown agent, and they become a scheme that gives order to the space that surrounds us and gives meaning to facts . Elements of representation such as a norm, a stereotype or an attitude are determined by the frequency of their appearance in the discourse or even by the number of links they establish with other elements. Other elements that speak of experience and depend on the context circulate are hierarchised and contain selected and interpreted information, value judgements, stereotypes, and beliefs . This article evidences the portrayal of students in a situation of school failure in the discourse of a specific educational community and the way in which other discourses are positioned around them, discourses that show the desire for school success but also individualise failure and generate situations of stigmatisation and rejection. --- Materials and Methods This study was carried out in a state school in southern Bogotá that offers both primary and secondary education to a low-income and highly vulnerable population. This institution produces low results in national standardised tests and has high failure and dropout rates . The research team belongs to this institu-tion; it is composed of the director of studies and educational counsellor. We designed a qualitative study with an ethnographic approach to give a voice to the students and to the educational community in general, giving meaning to their interactions and sense to their representations . This study approached the educational space from the sociology of discourse and from an ethnographic perspective to enrich theoretical development through the use of interviews and work in discussion groups. The stories of students and other members of the educational community allowed us to understand the richness of their experiences from their imaginaries, disagreements, desires, and interests . The study subjects were not selected based on psychological or demographic characteristics; rather, the initial criterion used was if the subject was a part of the researched group . Three students were selected as participants: two boys and one girl who study during the afternoon and who belong to the 6th and 7th grades in secondary school. These students are considered by teachers and peers as students at risk of possible school failure given their characteristics of low academic performance and disruptive behaviour in relation to institutional norms . The 6th and 7th grades were selected for this study because they are the grades with the highest failure rate among students in Bogota . The discussion groups and semistructured interviews were conducted by the teaching research team, of which one author of this article is a member and which has been recognized by the educational community for work carried out over more than a decade. The interviews with students and parents were conducted at the counsellor's office, as it is a real space of trust, which is different from the classroom and which is conducive to calm and open dialogue . Additionally, discussion groups were held with classmates of the subjects and their teachers. Two discussion groups were held, one with 14 students from the class to which the teenagers that are the focus of this research belong and one with 5 teachers who were in direct and weekly contact with these students through their classes and who expressed interest in participating in this research. These instruments were alternated weekly to not saturate the community with activities different from their daily work, and the schedule was flexible to ensure that they took place at a suitable moment for the participants. The names of the participants were anonymised to comply with international data protection regulations and the Granada University research code of ethics. All meetings and interviews were carried out with the informed consent of the institution, the parents, and the students themselves . The interviews were structured using open questions, which allowed for a greater expression of experiences. After each meeting, the teaching research team transcribed and showed the manuscript to the participants so that they could express their agreement or disagreement with the way their ideas and feelings were captured in it. Once the interviews and discussion groups had been conducted, they were transcribed. Each document was identified according to its origin and paragraphs were numbered , for example, St1.Int2.P6. After this, emerging categories and subcategories were identified, and key paragraphs were organized in tables by category, and thus the information obtained from each research member was summarised. A discourse analysis of the themselvesnterviews and discussion groups was carried out by the same research team. In both cases, the large amount of information needed to be broken down into groups of features and categories to find their sense and meaning, considering that this type of analysis allows for an objective, systematic and quantitative description of the content manifested in the discourse. Social representations, more than just organising ideas, are a sociocultural construction that arises from situations of exchange and in relation to the conditions under which the discourse occurs. They are influenced by the actions of the student in their group, and they arise in a context of relationships and communication that transcends the internal reality of the subject . Therefore, it is necessary to reconstruct them to know who produces the discourse, where and in which situations they do it and to whom it is directed. Following this, we proceeded to organise and categorise the information manually to highlight the ideas in the speech and quantify them depending on the meaning or topic which they referred to. The discourses were compared, and the information was hierarchised, with the intention of determining the main representations and their structure. Thus, the data were grouped into homogeneous sets that allowed us to identify relationships and inferences between the various topics analysed. Finally, the report was written. --- Results To analyse the results, it was necessary to understand how diverse social representations emerge in educational settings and how they configure a process of possible school failure from the differential construction between what represents a "good student" and a "bad student" via stigmatisation and confrontations with the school organisation to the increased risk of failing the school year, accompanied in many cases by exclusion. 3.1. The Construction of the "Good Student"-"Bad Student" Dichotomy: Desires, Hopes and Realities All students arrive at a school with their history, expectations and interests, and they must adapt to institutional and group dynamics, a situation that may or may not be easy since their desires or interests are not a criterion when selecting an institution from those on offer. In the institution, teachers follow the established school curriculum to determine skills, knowledge and behaviours that they consider a "good" student should demonstrate according to the student profile . Some differences are established between "good" behaviour and "inadequate" behaviour, and it is determined what is allowed from students and what is not. Thus, some students who are seen by their teachers and classmates as students who do not "adapt", who frequently break rules, who confront the teachers and who seek the attention of the class in order to make themselves visible begin to be considered "bad students" because they do not match the institutional student profile: they are "unpunctual" with class start times or in delivering assigned activities, they confront or challenge teachers, they have several notes in their student record because of their constant disrespect or irresponsibility, or they are always distracted; they "show little interest and indifference", "they hinder the work of others" or do something different while other students work, or they stand out because they "avoid classes", "are lazy", "do not study" and "do not do the minimum to pass". The school, represented by its teachers, establishes differences between students and carries out actions to make them behave as expected and become "normal" students. Thus, teachers can "give them opportunities" by explaining how to behave and how this can have a positive impact on their lives-academically, socially and familywise-so students become people who "are clear about their goals in life [. . .], who know what it means to study and what the school setting implies" . These students are expected to immediately fall into line, and much more is demanded of them. If they make a mistake, their negative image is reinforced, and it is shown that they are not suitable for school and that they are "bad students". Unfortunately, in these cases, teachers take the conflicts personally and seek to impose their authority: leaving them out of the classroom, excluding them from activities, giving them a negative image of themselves and warning them that "they will make a note in the student record, mum or dad will be called to the school, and they will have to sit out classes until their parents or guardians respond to the institution's call". Here the sanctions are to sit for one or two days in the coordinator's office [. . .] No, they send them home this year [. . .] when they should be given social work or something that really, I mean, leads them to reflect. I mean, here, first we must look at the type of sanctions that are being imposed or sanctions that the people in charge of doing it are imposing [. . .]. Sending them to the school counsellor and all of this? [. . .] In the case of. . .7th graders, last year, I can't give you any insight because I was not involved in their case. The student's case, the one I was most involved in, they were talked to. . .to them and his parents even took him to the EPS to see a psychologist [. . .] I must have the little sheet where the specialist gave some recommendations. These situations are rarely perceived by teachers as situations that concern them as well. They generally assume the situation to be the student's problem to be solved at home or through the school counsellor. In their opinion, the school does not have sufficient tools to manage this problem internally and for this reason, they resort to external authorities. Teachers' solutions are more oriented towards sanctioning or being indifferent. Well. . . it's not great. . . ; as I told you, there are people who keep their eye on us, and many teachers judge us without knowing, and it is horrible to hear how they talk about us: here comes the gang of arms and drug traffickers! You feel bad, besides it's all gossip; the teachers take a position based on what others say and based on appearances. They do not know the people well, they assume that everything is the way they are told, and that's where the problems start, the teachers listen and spread it: this one tells the other one, and the other one tells the other one, and so it goes, and the gossip goes on and on and on. That's when you get annoyed with some teachers, and you trust in others. Teachers attend to their students' difficulties in different ways: some within what is established in the Student Conduct Handbook and others on a personal basis according to what they believe should be done. Some teachers refuse to consider the institutional process in the Student Conduct Handbook, and they delegitimise it to regain control and power to prevent chaos from being generated: to bring "justice" and prevent "bad students" from continuing to "mistreat" the community. Other teachers are simply indifferent and almost ignore "bad students". What happens is that the manual has a problem, like the Constitution: it says many things "in words". But in practice, when it is time to apply it, it does not happen because the school itself is not legitimate in its actions [. . .] so that moment is when one loses the credibility to apply the manual; when those who should apply it do not use it, then these conditions are generated [. . .]. He was very haughty with me twice: no problem! I almost had to apologize to him. So that doesn't work here: this is why students generate their own ways of relating to each other: because they know that the manual is no longer valid [. . .] It is very general; that is, there should be a protocol for specific situations, and there is not. --- The Stigmatising Dimension of School Failure: Prophecy and Destiny The majority of state schools in Bogota serve a population with low socioeconomic and cultural status-with unsatisfied basic needs and a low level of family schooling. A good part of the social representations that are constructed around students at risk of school failure also come from the place where they have grown up and/or where they live: How is your neighbourhood? Normal What do you mean?. . . Well, normal: there are robberies, mugging;, but since they already know us, they don't do anything to us. There are good people and bad people as in any place and in every neighbourhood; there are people who feel superior. In the neighbourhood, there are different areas: the park, "la olla" and the block of "recyclers" and bars. How do you feel in your neighbourhood? I feel good, I know it and they know me, and I feel safe because I am from the neighbourhood. There they identify who is from the neighbourhood and who is not. It's not as unsafe as they say. Strangers see us in a strange way, they judge us, they see us as less [than them]. Influenced by this, many teachers have low expectations for their students, possibly on the assumption that families or social contexts with difficulties entail disadvantages in academic performance. On many occasions, the family is judged for not doing its part for the child's education, shifting the explanation of success or failure to individual situations. As you can see, yes. . . yes, because here there are children with different. . . as I said, with different types of education because of their family, their socioeconomic level, their beliefs; because of many things, there is a huge variety of children [. . .]. Other children, depending on the level of support from their family, well, one works with them. There directly with Instituto Colombiano de Bienestar Familiar [social services] located in the Timiza neighbourhood, last year, curiously, one person even helped me, through the Family Commissariat, and curiously he helped me with a psychologist he had there. So, it made it much easier for me to handle the cases because I worked on a case directly there, and it worked very well, but because of that help, right? And other cases it's like. . . There are some that, how should I say-they are like on "Stand By", or students leave, or for example, a case right now [of a pupil] in 703. It is a problem between the mother and the stepfather, and they are going to take away him and his sister too. Another aspect evidenced during this research was the "hidden" way in which these representations created about the students are constructed and transmitted, which leads to these representations not being expressing openly; rather, they are circulated in halls or in informal chats and not in institutional spaces such as teachers' meetings. They are created in informality but end up occupying institutionalism effectively, and they end up being accepted to avoid interpersonal conflicts because they come from figures with greater recognition in the community, who endorse and justify them. For example, to Professor "T", because he said that we were selling, that we were arms and drug dealers. If a student is permanently told that he is something [like that], they make him make bad decisions. Thus, when a "negative" social representation is constructed of a student, the views focus on the faults and mistakes they may make; meanwhile, their abilities are ignored, the level demanded of them is increased, and it is expected that the student will change and transform their behaviour following a telling off. When these expected responses are not obtained, this leads to prejudice and a sense of unease. --- The Attitudinal Dimension of School Failure: "This School Is Not for You" School difficulties affect the academic environment, which contradictorily values behaviour more than acquiring a certain level of knowledge in the subject. Even though the teaching staff may recognize this, they give failing grades to students with behavioural problems: [He failed the subject], but more for irresponsibility because he did not complete the tasks, but in terms of ability, he has it because there are other children that we as teachers, we see it is difficult for them, that they could not do the tasks [. . .] No, not at all, with me, he works, he does the things that I . . ., well let's say that. . . at the beginning, I asked him for things, but he was kind of lazy, so I know, why do I make the effort to write [in his notebook, or the student record]. . . I marked [what I received from him]; that's why he failed. There were days he was absent; he never showed up to tell me: teacher. . ., so I added up the grades he had, and he failed. Despite the low academic performance that characterises many of these students, they are recognised as frequent attendants of the institution, possibly motivated by maintaining a social and emotional link with their classmates: And what does he like about school? I think he feels bored at home; well, the. . . the girls-he has a lot of female friends. I tell him "Oooh!" because he is very sociable, because his friends begin to come to our home: one girl, another one, another one [. . .] He has a lot of friends, I mean, men and [. . .] girls and men, and well, they love him [. . .]! When it is his birthday and so on, they give him cards, they write him things. I mean, he is very sociable; well, I think he misses it at home, and he likes coming to school [. . .] Well, you see that his classmates go to look for him, and they are from here at school because you see them in uniform: they are all from the same school, right? They go. . . and sometimes one afternoon they watch movies, and you see that they are good kids! Why do you feel good even though you are not good academically at school and teachers tell you off? Because I spend time with my friends and play with them; I laugh. However, despite their qualities as people, they come into conflict with the institutional norms that some teachers legitimise and validate in their classes or the demands that individual teachers make of students. They get used to the norms that apply in the school [. . .]. In that way, these norms must be established so things work [. . .] And what happens is that the hidden curriculum that the students handle plays an important role: knowing with whom they behave and in what way. In that case, we ourselves are to blame because they go to a teacher's class and in this teacher's class there is a certain behaviour, and if they change teacher, there is another behaviour; so here, as teachers, we are all heterogeneous; there are no rules that make us all behave in the same way. So the children, in their hidden curriculum, say "let's go to such and such a class, and they know we go to the bathroom, we go to the playground, we go to buy a soda, and then if we go up to the classroom, we do not have any problem". So, I think that, as such, the children do get used to the rules of the institution; it is clear, they get used to norms [. . .] Or, at least, to the rules that each teacher has". The rejection of these students and the inadequate or indifferent handling of their situations increases the problems in which they are involved. Stigmatization, the use of disparaging language, prejudices and the harshness with which they are told off are some circumstances that damage their self-esteem, increase their resentment, affect their interpersonal relationships , demotivate them in their learning and end up reinforcing behaviours that are criticised, placing them in situations of greater risk. Well, if for whatever reason, you don't do homework, then they start yelling at you and tell you off for everything, so I behave badly. When the expected changes in the attitude of this student do not occur, the student becomes more "rebellious": they tire of staying quiet about the negative comments they constantly receive, and they react. This act is taken as a sign of disrespect, their parents are summoned, and some teachers begin the job of tarnishing the student's image in front of them, so parents feel their child is getting worse and worse and believe the school is not the best place to be. This generates conditions such that in the next conflict, the guardian gets tired of the situation and decides to withdraw the student. When this happens, some teachers feel proud because they "solved" the problem and demonstrated who had more power and was right; they reaffirm their authority through fear and consolidate the veiled idea about the good behaviour with certain teachers because they can "get them out of the institution". Well, firstly we should not bethemselvese: last year, people who were causing a lot of trouble were taken out of the school: those who scammed, those who extorted, the violent ones, the hooligans. So, that had an impact. Secondly because, as the "prize issue" [avoiding punishing students with poor behaviour] had gone too far and the boys had started to understand that the prize issue came from the headteacher's office, then we had to generate our own ways to solve the situations: relocation or expulsion. The lack of institutional organization, the ambiguous handling of the situations and the disregard for rights and of the Convivence Handbook by a great number of members of the community are some of the situations that end up institutionally justifying the withdrawal of students with characteristics that they consider incompatible with how they should behave. --- Discussion At school, behaviours and abilities are naturalised and normalised, and based on them, categories of students are constructed: those who are intelligent, those who are responsible, those who are lazy, those who never achieve and those who would seem not to want to achieve . These classifications are not natural, but they have their origin in school, social and family relationships . Additionally, these labels and other situations affect the way students are seen by others and undoubtedly in their school life since representations are built about some of them that at first, classify them as "bad students" and later, if behaviours discordant with the established norms are added, label them as problematic students at risk of failing and even being excluded . "The essence of a representation is to make people understand and share an idea with the same vividness as a perception or an emotion, and vice versa" . A student's life conditions determine, to a great extent, the way they hey construct themself as a subject and relate to other people. Some typical life conditions in Bogotá include, for example, if the student comes from a family where the student receives care, if they have a father or mother who has received education, if they have a large family or one with economic difficulties and if they arrive to school hungry or with other needs . It is important to emphasize that family economic level plays a decisive role in teachers' expectations, and when they do not know a student's situation, they assume it is negative and speak about it in a pejorative and prejudiced way, referring to "unfortunate or unstructured families" and ignoring societal problems . Many teachers' expectations are determined by this economic status, which is associated with success or failure, with greater or lesser intelligence or with the effort made in activities, tests, or exams, among others . The well-known "Pygmalion effect", in which expectations are a destiny to be fulfilled , can generate real effects on students, as "education is a deeply emotional practice and, through their expectations, teachers transmit positive or negative emotions, attributes, stereotypes, stigmas, affections and disaffections, which characterise educational relationships in the everyday" . Classmates or the class group also play a decisive role as the other significant subjects who inhabit the school ; in other words, they are people who determine the self-image and the world around students and who influence their actions and relationships. Additionally, the social representations that are built of students at risk of school failure are also influenced by the representation of the place where the educational centre is located or which its students come from . In this case, as the school is located in the south of the city, which is an unsafe residential and commercial zone, the location arouses fear and some repulsion towards its inhabitants since frequent criminal episodes occur there . The representations that teachers construct of their students determine some of their practices , especially in the case of "bad students": tellings-off, shouting, observations in the student record, summons to parents, suspension, and expulsion from the school, among others . In this sense, representations take shape in other areas of the school as well: "The teachers' room" [. . .] is a space for interaction among teachers, where many assessments, both positive and negative, are transmitted about different students. The classroom is one of the spaces in the school where the differentiation process takes place, which is reflected in preconceptions about better and worse students. The common denominator of the response to situations involving these students is to exclude them from the classroom, from activities or from the institution itself. Moscovici analyses what happens in this sense, when he states that social influence aims to maintain and reinforce social control as, for it to exist, it is necessary for the educational community to have the same values, norms and judgement criteria , which exclude those who refuse to change. Those who are considered "bad students" or "troublemakers" are led to believe that they are wrong, that their behaviour is abnormal. The group in power-the teaching staff-seeks uniformity and employs cohesion and attraction as strategies to attract new members and reduce the distance with dissident minorities . Social representations materialise in cultural agreements, such as acting in one way or another in certain scenarios such as school and rejecting strange behaviour when it deviates too much from the norm, as it threatens the established order. The representations teachers construct around "bad students" or those that are at risk of school failure are constituted in relation to what they consider a "good student" or a "successful student" and transmit perceptions of reality that influence the school environment . The judgements that are made about someone depend, to a large extent, more on the social representations in which they are included than on their intellectual capacities and behaviour . These representations are explicit both in discourse and in practice, and they acquire further legitimacy due to the authority given to teachers. They seek a uniform student group largely because they were trained under beliefs and norms that demand a nonexistent homogeneity and which consider that it is the student who should be standardised and adapt to the school . The educational system's demand to value students according to their knowledge, skills and behaviours and the absence of teacher training to manage diversity have generated pedagogical practices that must be eradicated from the school. --- Conclusions School failure is one of the main problems that must be tackled using diverse educational policies, and in this way, it is imperative to assume that "educational centres, far from being mere large-scale social viewers, are active agents in producing processes of success, failure and school dropout" . Current educational policies based on standards prioritise results and do not tackle educational practices that discriminate, undermine teacher-student relationships and use standardised curricula and exclusionary methodologies that are insensitive to the realities in the school . It is necessary to ask ourselves about school failure itself and its possible causes, as educational policies are interrelated with how this phenomenon is managed inside an institution and even more in terms of teachers' responsibility regarding failure. There seems to be a three-way solution: designing inclusive educational policies, nurturing a culture of inclusion and adopting inclusive educational practices . Inclusive education policies should be based on teacher training that favours pedagogical relationships based on otherness and participation, which arouse the desire to know and which facilitates students' affective development. This training should aim to help teachers as a whole change their expectations regarding those they consider "bad students", set high goals for them and allow them to generate confidence in their abilities . The school's responsibilities are to seek consolidation of a socially responsible teaching culture : one that recognises the effects of the teaching-learning process based on empathy, that reflects on the possible biases of its practice and that is able to understand what is happening rather than just validating its supposed neutrality. This culture should be based on practices of respect, care, listening and otherness rather than prejudice, stigmatization, or authoritarian and exclusionary practices. In this culture, teachers, in accepting their role, understand that teaching requires more than just knowledge of their discipline: it needs a knowledge and pedagogy that are more empathic and a response to their calling as educators in the most general sense. In adverse contexts, teachers in particular carry the social responsibility of alleviating and empathising with the social suffering of students [. . .]. The instances of reflection on practice can allow teachers to learn to know their students in terms of their identities, and material and cultural constructions, without prejudging them, without condemning them in advance; and as a result, they can be in better pedagogical conditions to interact with them. Although this research has some limitations in its implementation , far from seeking generalisations, were able to identify the connection between the social representations of those who are considered "bad" students with their low academic results and the corresponding school failure. It is important to give voice to these children who are colloquially referred to as "bad students" and considered by the school as "problem cases" and to be receptive to what they think, what they feel, what they need from the school and the causes of their behaviour. As well as being a possible direction for future research with a narrative approach, the diversity and heterogeneity of students can and should be an area to be reviewed and recognised in teacher training Understanding and getting closer to their students' world to deconstruct representations and stereotypes that exclude or discriminate is an unresolved task for teachers. It is therefore necessary to rebuild teacher-student relationships based on the recognition of the other and their abilities through dialogue to establish bridges of communication, affection and collaboration to manage diversity in the classroom. Today, the important thing is to connect with the lives of the students, their interests and needs and to engage them with learning and the institution so that they feel like an important part of it. Only in this way can we change the foundations of the current education system and make school a more welcoming place for students and their learning. --- Data Availability Statement: Data from this research and support for the findings of the report can be found at the following link: https://internoredpedu-my.sharepoint.com/:f:/g/personal/avelasc4 _educacionbogota_edu_co/EomyV9fCsMpJrT0TAQPhp0IBOWfQs7uMbGxI09Mjr-H61w?e=Q8B8vB . --- At what point do you consider a student is having difficulty? How do you describe this kind of student? How do you interact with them? How do they interact among themselves? What are their learning processes, learning rhythm and behaviour? What happens to these students? What are the reasons for their difficulties? How do these difficulties affect your classes? What consequences has this situation had on the student and the whole group? What are the institutional guidelines to manage these cases? What is the process you follow to manage a student who presents difficulties ? What can you do to help this student? What would be the best way to act in these cases? --- Parents How do you think about your child as a student? How do you think your child feels at school? How is your child doing at school? What are your child's strengths and weaknesses? How has your child's school life been? Why do you think they behave in this way? What consequences has it had for your child? How do you think you can give help to your child? --- Group discussion script --- Student's Group In your opinion what kind of students should be at school? What are the main difficulties your fellow students have? What are the reasons for these difficulties? How do we act and how should we act to face them? How can you determine that a teenager has an academic or behaviour difficulty? In which cases should a student be excluded? Funding: This research received no external funding. --- Institutional Review Board Statement: The study was conducted in accordance with to comply with international data protection regulations and the Granada University research ethical code. Informed Consent Statement: Informed consent was obtained from all subjects involved in the study. ---

Social representations can influence, to a great extent, the way in which we relate to people in different situations. In the educational environment, these representations-in terms of their adaptation or not to the school's academic and behavioural demands-can lead to the school failure of those considered as "bad students". Following an assessment, interviews and discussion groups were conducted with various members of an educational institution in the south of Bogotá to describe the social representations that prevail in this community about students who were at possible risk of school failure and how these representations could determine whether or not the student does indeed fail. Discourse analysis results yielded categories such as the differential construction between a "good student" and a "bad student" as well as stigmatization and conflicts with the school hierarchy and also showed how, occasionally, student failure is considered a consequence of family or social and economic factors unrelated to the school itself and to pedagogy. In conclusion, it is evident that there is an urgent need to establish institutional mechanisms that promote and adopt inclusion in educational relationships and practices from the perspective of the needs and interests of the most vulnerable pupils.

Background Debates about the widespread advertising of gambling products, the increased availability of fixed-odds betting terminals, rising participation in online gambling and the growing prevalence of problem gambling regularly feature in the UK media . Unsurprisingly, gambling-related harm has attracted more public health attention since the industry was deregulated in 2007. Furthermore, gambling-related harm is increasingly identified as a potential public health problem within leading medical and scientific communities . Gambling-related harm is defined as 'the adverse impacts from gambling on the health and wellbeing of individuals, families, communities and society' . Currently, attention is being focused on identifying the types of gambling-related harm which people may experience, any associated risk factors and populations who may be particularly vulnerable to gambling-related harm . The term 'vulnerable adults' is used for UK regulatory purposes, meaning 'people who gamble more than they want to, people who may not be able to make informed or balanced decisions about gambling due to, for example, mental health problems, a learning disability or substance misuse relating to alcohol or drugs' . Individuals working in primary care, social care services and third sector organisations come into contact with a wide range of individuals, some of whom may be experiencing gamblingrelated harm. For example, a survey of patients within 11 UK general practices found 0.9% exhibited problem gambling . GPs working in Solihull, England reported seeing patients experiencing gambling-related harm, but many GPs had not received any training in relation to how to identify and treat gambling addiction . Therefore, the question of whether GPs, health and social care professionals working in the UK could or should do more to address problem gambling has been discussed, with low levels of awareness of problem gambling being identified as potential barriers to practitioners becoming involved in the identification and management of problem gambling . The English Local Government Association observed that gambling problems affect the health and well-being of local communities and wider society, and urged local government, with partners, to develop a coherent approach to problem gambling, with a focus on preventative work with high-risk groups. It recommended that local health agencies should raise awareness of problem gambling among primary care professionals and work with local government to direct people to local and national support services. It advised mental health service providers to consider how to better identify problem gambling and provide access to specialist support. Local audit, clinical and public research and evaluation of interventions across health and social care partnerships were described as having the potential to support the national evidence base and develop the 'business case' for intervention. Licensing, planning, trading standards and local government scrutiny processes were identified as needing to bring together public bodies and gambling operators to establish the nature and extent of local problems. Recent scoping reviews ) have noted the lack of evidence about the nature and impact of gamblingrelated harm on adults with health and social care needs and prompted this present study. Service-related data about gambling-related harms do not generally distinguish those affected by health or care needs from the general population, although estimates of the extent of gambling behaviour have been calculated in respect of some groups, for example, homeless populations . Furthermore, evidence of a 'harm paradox' has been obtained for migrant populations suggesting that migrants may be less likely to gamble but more likely to experience gambling-related harm . --- Aim The aim of this study was to explore the views of key informants working within health, social care and other agencies about harmful gambling among adults with health and social care needs. --- Method --- Sample and recruitment We devised a sampling framework to provide a broad range of interviewees and sought volunteer participants from different services and organisations. We explained that the study was explorative and that no patient or service user data would be sought or identifiable data reported. Informed consent was obtained before interviews commenced. Semi-structured telephone or face-to-face interviews were conducted between September 2016 and May 2017. Twenty-three key informants involved in the care and support of adults with health and social care needs from National Health Service , local government, charities or third sector organisations and gambling experts were interviewed . --- Materials The interview schedule consisted of open-ended questions designed to capture key informants' experiences of working with people with health and social care needs who had experienced gambling-related harm . Interviews were audio recorded, with consent, and transcribed. --- Data analysis Transcripts were inputted into NVivo7 to facilitate data analysis. Data were analysed using thematic analysis which enabled the authors to scrutinise data in detail through identifying, analysing and reporting themes within data . We followed the five phases of thematic analysis - familiarisation with the data ; generating initial codes; searching for themes; reviewing themes and defining and naming themes . --- Findings Four main themes were identified in the data: gambling as a public health problem; identification of groups of adults with health and social care needs who may be vulnerable to gamblingrelated harm; factors potentially impeding the identification of gambling-related harm among adults with health and care needs and subsequent help-seeking behaviour and call for professional development activities. Gambling-related harm as a public health problem Many interviewees considered gambling-related harm as a public health problem and identified ways that gambling had negatively impacted on adults with health and social care needs. One interviewee reported gambling participation initially as a distraction for patients but became a habit and ultimately an addiction or provoked high anxiety. The potential consequences of gambling included financial difficulties leading to other problems including depression, with one interviewee commenting 'and then they not only have to get help for their addiction, but also how they're going to cope with their money difficulties as well' . Interviewees also reported challenges when supporting adults with health and social care needs experiencing gambling-related harm. A gambling support charity had been supporting a man with several mental health problems but, when his inheritance ran out, he gambled with his benefit payments. The charity liaised with his housing provider and other charities to build a routine for him, but the man refused to engage with mental health services and consequently his mental health was negatively affected. However, unlike many other public health concerns, gambling participation was not always viewed negatively. Gambling participation was seen as a positive activity helping people be active, be social and engage in activities which they participated in prior to illness. An Occupational Therapist specialising in mental health and older people provided an example of where a client's family supported his gambling because 'he used to go to the betting shop : : : . it got him out of the house, he would see people in the betting shop, which would make it into a social activity'. Nevertheless, interviewees argued that the responsibility for addressing gambling-related harm should be shared by industry, government, the regulator of gambling and local authorities. However, because the vast majority of funding for UK-specific gambling support services comes from voluntary donations from the gambling industry, one interviewee thought that government should seek to increase industry contributions . Others called for a national strategy to tackle gambling-related harm, as exists for substance misuse: -"I don't think it's any different to alcohol or cigarette addition : : : if we deal with those in the NHS : : : . then why shouldn't we deal with gambling addiction too?". Identification of groups of adults with health and social care needs who may be vulnerable to gambling-related harm Interviewees were asked to identify groups they thought might be vulnerable to gambling-related harm. Broad descriptions were obtained, some of which were circular, 'anybody with gamblingrelated harm is vulnerable' . The same interviewee thought that there were risks to almost everyone, 'there's always potential for that harm to escalate; there's always potential for that harm to cause other harms'. Some interviewees listed specific medical conditions they thought may be associated with gambling-related harm. Examples featuring people with mental health problems or dementia were provided by several interviewees. One clinician considered that people with: " : : : no confidence, no self-esteem : : : a person who might have learning disabilities, somebody who is perhaps demented : : : people with posttraumatic stress disorder : : : , people with eating disorder, people with substance misuse and dependence might experience gambling-related harm". Another thought that people living with schizophrenia or bipolar disorder could experience gambling-related harm . Older people might also be vulnerable because of changes in circumstances, 'bereavement, loss of employment through retirement : : : loss of their status in society : : : feeling depressed because they're lonely, isolated' . An Older People's Charity Employee summarised the appeal of betting shops for older people -'if they go into a betting shop and get a smiling face from someone, and they don't see anyone else, then they might well go back because they're going to get a smiling face and maybe a few coffees as well'. The appeal of gambling environments as places of safe social interaction emerged within another example from Gambling Charity Employee 2 who had been asked by the local NHS mental health service to discourage a patient from spending his benefits in betting shops. However, 'it became quite clear : : : actually, this was such a key part of his life, we couldn't just say stop going : : : that's not going to work; we would have to do a more prolonged piece of work where we're offering alternatives to him'. Being in the betting shop alleviated anxieties: 'he was quite stressed, quite anxious and for him to be going to an environment where they're very friendly towards him, give him tea and coffee, etcetera, that was a very powerful experience for him and it wasn't one he was ready to give up'. Further specific examples concerning people with learning disabilities were provided. A Trainer provided information about a young man with learning disabilities who plays bingo: 'every time I see him he always tells me about what he's won; never tells me what he's lost, and he really doesn't see the risk'. The interviewee considered his parents encouraged gambling because 'he has challenging behaviour, and they quite like it when he's not around. They want some time to themselves' . However, they Primary Health Care Research & Development predicted 'it won't be long, I believe, before he starts : : : getting into more serious gambling, visiting casinos'. Concerns were growing about his use of benefit payments for gambling. There were accounts of people with learning disabilities being supported by gambling venue staff -'they were sort of looked after almost by some of the staff, they would make sure they weren't getting fleeced or taken advantage of by maybe not understanding something' . Such customer care was reportedly undertaken without guidance from their employer. It had extended in one case to escorting a customer home, so that he would not be subjected to verbal or physical abuse by local children . However, a small number of interviewees commented on individuals who had 'ended up blowing a huge amount of money in their local betting shop' without any intervention from staff . People with mobility problems were also considered to be vulnerable to gambling-related harm. A Counselling Services Manager recalled a wheelchair-using client who seemed to be using online gambling as a coping mechanism. An Autism Charity Employee commented on the potential dangers of gambling for people with autism; in their view, avoidance of asking for help is characteristic of the condition: "someone could spend hours in a betting shop analysing things and reading the stuff on the walls : : : it can : : : really draw people in, and so if you've got that kind of autistic mind-set, then I wouldn't be surprised if a lot of the people spending all day in a betting shop, some of them are on the spectrum". People experiencing homelessness were thought to be vulnerable as they could get 'a free drink and a bit of warmth' in high street betting shops . Such environments may also be perceived as 'a different space to be in : : : a space that's less judgemental and visible than some other public places' . Homeless people may gamble in order to do 'something they can control and make decisions about' and perceive betting shops as 'a constant, familiar place that you can access and feel the familiarity and somewhere you would feel relaxed, or at home' . People who lack mental capacity or live with cognitive impairment were mentioned as potentially vulnerable to gamblingrelated harm as they may not have 'an understanding of the implications of it for them now and in the future' . This view was echoed by another interviewee who remarked that some individuals may continue to gamble but 'don't really understand what it is they're doing' and 'may not be aware of the eventual outcome' . Certain prescribed medications were also identified as a factor which may contribute to gambling-related harm. GP1 considered that selective serotonin reuptake inhibitors were 'associated with increased risk-taking in vulnerable people'. They also reported that dopamine agonist drugs, which may be prescribed to people diagnosed with Parkinson's Disease were associated with increased risk-taking but thought it would be: " : : : pretty unusual to use those in the same group where you're concerned about gambling. I don't think that's a massive contribution factor to people's gambling problems, because : : : they're mainly used in Parkinson's and : : : so you're mainly talking about people in their 80s and 90s who are far less likely to be gambling". However, the Frontline Services Manager for a gambling charity reported that 'it's a documented fact that some of the medication associated with Parkinson's Disease can lead to a reduction in inhibition' and said they had received calls 'from partners, children, where they're concerned about an elderly relative'. Furthermore, dopamine agonist drugs were referred to by a Parkinson's Disease Nurse who recalled the case of a patient who had never gambled but then spent thousands of pounds on online gambling activities: "She was saying, information is so readily available, on the TV, on the internet and she could even use a Kindle as well as a phone, and she just couldn't resist that urge, and was completely overwhelmed by it". This interviewee also reported cases where spouses had telephoned their service to seek help for a relative who was taking dopamine agonist drugs and 'spending huge amounts of money' . Factors potentially impeding the identification of gamblingrelated harm among adults with health and social care needs and subsequent help-seeking behaviour Within the interviews, many identified a number of factors which may potentially impede the identification of gambling-related harm among adults with health and social care needs and individuals who experience gambling-related harm engaging in helpseeking behaviour. Interviewees identified that there was no pathway or guidance to follow in relation to the diagnosis, assessment and management of gambling within primary care, which differed from other addictive behaviours such as smoking, alcohol and drug misuse. Therefore, professionals working in primary care did not screen for gambling-related harm. Gambling was described as an 'under-detected problem' by one GP . Another GP reported that he did not ask about gambling problems during consultations because the NHS does not 'have an answer to it, so we don't look for it' and because 'a lot of medicine is based on having a solution to a problem, if you have the solution, you can see the problem. If you don't have a solution, then you tend not to want to see the problem'. A Psychiatrist considered that the identification of problem gamblers would 'very much depend on people presenting themselves with a problem, rather than it being identified through a systematic method'. Other interviewees acknowledged that the lack of visible signs of gambling-related harm compared with the signs of alcohol or drug misuse may contribute to professionals being unaware that adults with health and social care needs may be experiencing gambling-related harm. A Counselling Services Manager compared the signs of alcohol and drug addiction to gambling -'you don't see gambling addiction sitting in front of you : : : there's no physical, : : : direct physical consequences, where there would be with someone who's a heroin addict or an alcoholic : : : it's less visible'. He added that while there 'are a lot of tell-tale signs in terms of behaviours, but at the same time, a lot of problem gamblers are able to conceal'. Therefore, the family members of adults with health and social care needs experiencing gambling-related harm may also be unaware that gambling is impacting upon individuals. For example, gamblers may 'apprehend the mail : : : make sure no one sees their laptop or tablet or phone' in order to hide their gambling. Professionals may also only encounter instances of gamblingrelated harm after a prolonged period of time or when an individual is no longer in receipt of a service. A homeless charity discovered, by chance, the extent of a client's gambling participation 'when we were clearing each room and found all the gambling receipts'. Interviewees' responses indicated that the onus was placed on adults with health and social care needs to disclose any gambling problems. However, such disclosures may be unlikely to occur if individuals are living with a number of medical conditions because gambling problems may not be 'top of the agenda' . This view was supported by another interviewee: "one particular client that we were aware of gambling regularly had suffered a brain injury, was a dependent drinker and was occasionally using drugs and may or may not have had other mental health issues that hadn't been diagnosed because the brain injury and alcohol addiction were the presenting issues, so we hadn't been able to do further work". Several interviewees also identified factors which may impede adults with care and support needs engaging in help-seeking behaviours. Inaccessibility was one reason, as services are not widely available or known about . Other barriers included costs associated with travelling to the treatment provider and service limitations . Also mentioned were poor communication skills, feeling ashamed or embarrassed, fear of losing welfare benefit payments , difficulty keeping appointments and problems such as depression affecting help-seeking. The provision of services available to those experiencing gambling-related harm was also thought to potentially impact upon help-seeking behaviour by adults with health and social care needs. Waiting lists for NHS-funded services which may be able to support those experiencing gambling-related harm were perceived to be too long. Furthermore, the priority given to gambling problems was thought to differ between NHS-funded services and private-funded services. Private services tend to recognise gambling 'as a primary addiction requiring rehab and on-going support', whereas the NHS tended to prioritise the treatment of other co-morbid conditions or treat the addiction and not the other condition . Calls for gambling-related harm to be better tacked by the NHS were made by several participants. --- Call for professional development activities Most interviewees, apart from those working within gambling support services, were generally unaware of the types of support available to adults with health and social care needs experiencing gambling-related harm. Therefore, treatment options were not generally discussed by interviewees. Exceptionally, one interviewee outlined the case where a patient had unsuccessfully completed a year's course of Cognitive Behavioural Therapy because she could not process or retain information. The patient was still spending her benefit money in betting shops and begging in public. Although this patient would never 'reach rock bottom because she's in supported housing', the support workers called for professional development activities which focused on being able to identify 'red flags' or triggers for problematic gambling. There was little awareness of gambling management tools to which practitioners could signpost adults with health and social care needs so as to help them to control their gambling participation. Such tools include setting time and monetary limits when gambling, self-exclusion schemes and software, which prevent individuals from accessing online gambling websites. One interviewee reported that it might be beneficial for practitioners if there was more partnership working and links formed with specialist gambling services. For example, a charity had forged a partnership with a gambling support charity, and this was perceived to help them feel equipped to support adults with health and social care needs who were at risk of experiencing gambling-related harm. Another interviewee suggested that gambling operators could alert a professional if 'they're worried about somebody' . This view was shared by another interviewee who thought that forming better relationships between gambling operators and support agencies would help both parties gain 'valuable advice and guidance' . Another considered that 'working in a much more co-productive way' would facilitate sharing of expertise, skills and knowledge . Some interviewees thought that pathways and guidance needed to be developed, so that practitioners could signpost adults with health and social care needs to support services and encourage individuals to engage in help-seeking behaviours. Several also thought that it was important for practitioners to receive training via professional development activities so as to improve their knowledge of gambling-related harm. Furthermore, some thought that information about gambling and gambling support services should be developed for dissemination by practitioners to adults with care and support needs. However, it would be important for this information to be accessible -'Some of the information that is given out about the consequences of gambling may not be easily understood by somebody with cognitive difficulties, somebody that is not good with words : : : so : : : . much more pictorial information : : : . available in a number of formats' . --- Discussion This interview study explored practitioners' knowledge about gambling-related harm among adults with health and social care needs. Representatives from organisations working with adults with care and support needs drew on their experiences to discuss services and possible public health measures to address gambling-related harm, echoing calls made by Bowden-Jones , Griffiths, S. , Griffiths, M. and the Responsible Gambling Strategy Board . Some interviewees considered gambling-related harm as a public health issue and called for it to be recognised as such. This was because gambling was thought to impact some individuals' mental health, financial situation, housing situation and relationships. In addition, several identified that loneliness, feeling unsafe, being isolated, taking SSRIs or dopamine agonists could be risk factors for adults with health and social care needs experiencing gambling-related harm. However, several interviewees acknowledged that gambling could be a positive activity for some individuals. Ideas of who might be vulnerable to gambling-related harm ranged from a broad definition to those with specific health conditions to specific population groups . Such ideas emerged from experiences of clients/patients who seemed to be experiencing gambling-related harm. This knowledge could be used to screen certain population groups, target health campaigns and direct practitioners' efforts to help affected individuals to manage their gambling participation. Apart from those who worked for gambling charities, no other interviewees discussed gambling during consultations or screened for gambling problems during initial assessments. There were strong feelings that people did not disclose their own or others' gambling problems, and therefore, indices of gambling-related Primary Health Care Research & Development harm were sometimes only discovered by chance. These experiences highlight possible opportunities for those involved in the support of adults with care and support needs to be more aware of gambling as a potentially problematic behaviour, trained so that they can have open and probing conversations with their clients/patients and their carers or supporters, and be equipped with knowledge of where to signpost affected individuals to treatment, counselling or safeguarding services. There may be opportunities for more professionals working within primary care, including GPs, nurses, pharmacists and receptionists to be involved with signposting, making referrals and providing affected individuals with a space to talk about their gambling problems. Overall, there was an underlying theme that none of the organisations could address these risks alone and partnerships were needed between organisations including the NHS, social services, housing and care providers, and the gambling industry in order to minimise the risk of adults with care and support needs experiencing gambling-related harm. Such partnerships may help improve care for those experiencing gambling-related harm as practitioners' knowledge about gambling-related harm should improve, practitioners may feel better equipped to identify affected individuals and refer people to support services. The interviews provided insights into what these largely nonspecialist key informants know about harmful gambling among adults with health and social care needs. However, limitations should be borne in mind. First, our sample was purposefully recruited and only 23 interviews were conducted. Larger studies would help determine the views of others who support adults with health and social care needs. Second, interviewees may have recalled cases that caused them concern, only partially recalled cases, recalled exceptional cases and/or those which occurred some time ago and so may be subject to risks of hindsight; we did not ask them to review case notes or similar. Nonetheless, this study provides a springboard for other research and its contemporary nature highlights the increasing practices of gambling online and by phone, with their consequent invisibility. --- Conclusion Those working across a range of health and social care agencies, third sector, charity and other organisations report encountering cases of gambling-related harm among adults with care and support needs. Interviewees highlighted a need for pathways and guidance to be developed, together with professional development activities to improve awareness of gambling-related harm and professionals' ability to support affected individuals. --- Author ORCIDs. Stephanie Bramley 0000-0003-2702-1672, Caroline Norrie 0000-0001-6715-9305, Jill Manthorpe 0000-0001-9006-1410

Aim: To explore the views of professionals working within health, care and other agencies about harmful gambling among adults with health and social care needs. Background: Gambling is increasingly seen as a public health rather than an individual problem. Opportunities to gamble have grown in England in the last decade since the liberalisation of the gambling industry meaning that gambling is widely available, accessible and advertised within society. An estimated two million people in the UK are at risk of developing a gambling problem, some of whom may be adults with health and social care needs. Methods: Twenty-three key informants from primary care, social care services and third sector organisations in England were interviewed about their understanding of the risks to adults with health and social care needs from gambling participation. Findings: Thematic analysis revealed four themes: (1) gambling-related harm as a public health problem; (2) identification of groups of adults with health and social care needs who may be vulnerable to gambling-related harm; (3) factors potentially impeding the identification of gambling-related harm among adults with health and social care needs and subsequent helpseeking behaviour and (4) calls for professional development activities. Informants reported a perceived lack of awareness of gambling-related harm and a lack of a clear pathway or guidance which they could follow when supporting individuals experiencing gambling-related harm. Interviewees called for professional development activities to improve their knowledge and expertise in this area.

Introduction Scholarly and programmatic interest in individual and community resilience has grown exponentially over the past fifty years. What began as a focus in the field of developmental psychology to understand how children may thrive despite growing up in adverse conditions or with schizophrenic parents 1,2 has expanded to embrace a broad political interest in --- Background The Gulf Coast communities of Texas, Mississippi, Louisiana, Alabama, and Florida are at risk for significant adverse mental health outcomes as a result of exposure to the Deepwater Horizon Oil Spill and related persistent stressors from previous adverse events and recurring life challenges. Despite diverse occupational, ethnic, and subsistence lifestyles, all of these communities share strong economic, social, and cultural ties to the Gulf of Mexico and its renewable resources. These communities were significantly impacted by the DWHOS environmental disaster and continue to experience uncertainty regarding future environmental, economic, health, and social impacts. Early DWHOS studies documented negative mental health outcomes in selected Gulf Coast subpopulations in the immediate aftermath of the spill . Similarly, studies of community reactivity are underway in select regions documenting signs of community conflict, corrosion and economic distress. 12,14,15 However, despite the fact that, 1) the resources of the social/community environment are strong mediators of postdisaster mental health in the individual, and 2) communities are made up of individuals who bring a wide range of psychological reactivity to community adaptation, no research to date has comprehensively addressed the link between how mental health is shaped by attributes of individual and community resilience, and whether there are means of activating such resilience through informal social supports and through health-and social system interventions. Recent definitions have approached resilience as a process rather than an outcome; for example, resilience as "the capacity of a system to withstand or recover from significant disturbances that threaten its adaptive function, viability or development." 16 The system is scalable: it may be an individual, a household, a community, an institution, or a nation-state. Furthermore, there are two distinct elements in such a resilience process. First, there has to be a "significant disturbance" sufficient to disrupt or destroy the system. Second, the system's resilience capacity is then revealed by how well it is able to withstand, adapt, or recover quickly from the potentially traumatic event. Resilience attributes are those traits and characteristics of a system that permit it to conserve or marshal its resources. Figure 1 illustrates these attributes as functions of four types of "capital" -human, economic, social, and political -that may be present at individual or collective levels. The framework is based on the notion that a resilient individual or community has the capacity and capability to maintain, re-establish, acquire, or exchange these critical resources. In an effort to develop a hypothesis-driven framework, it is assumed that in the face of a stressor these resources can be deployed by individuals and communities to counter the effects of the event. For example, an individual with good health , adequate insurance and savings , and a strong social network will be able to call upon all of these resources to help buffer the effects of a catastrophic event. Communities with highly effective and equitable government infrastructure , ready access to public and private funding sources , and communal norms of neighborliness or collective self-efficacy , should be similarly positioned to buffer a stressful event. The use of these resources may be an expression of an individual or community's resilience attributes , or it may be accessed by specific resilience actions . This conceptual framework is predicated upon the following premises, each of which will be explored in greater detail in subsequent sections: 1) exposure to harm leads to resource loss, stress, and psychological reactivity; 2) most people are inherently resilient; 3) community resilience attributes interact with individual resilience attributes; 4) access to or engagement with community/social resources can activate inherent individual resilience attributes; 5) this activation takes place within the context of a sociocultural milieu that moderates resilience capacity; and 6) individual, community and sociocultural milieu can be quantified and measured in order to test various components of the framework. Building upon the research efforts of the RWG with the Deepwater Horizon Oil Spill and other disasters to date, a conceptual framework is proposed hypothesizing that access to social resources can activate resilience attributes that are inherent in individuals and communities, and in so doing lead to better psychological adjustment, health, and well-being. --- Premises of the Resilience Activation Framework 1. Exposure to harm leads to resource loss, stress, and psychological reactivity-Large scale disasters are relatively common events with catastrophic consequences for many people. In the "face" and "wake" of disaster, individuals may suffer the loss of loved ones, health, homes, financial stability, social support, sense of stability, or other resources important to daily living. 17 As a result, impacted people demonstrate a wide range of psychological reactivity ranging from brief, transient distress to long term psychopathology. The chain of events that links disaster to mental health and behavioral problems is neither simple, nor linear. In contemporary psychology, however, a reasonable starting point for explaining this dynamic process is Hobfoll's Conservation of Resources model of stress and adaptation. 18,19 The COR model postulates that people are driven to acquire, preserve or protect valued resources. These resources include objects , conditions , personal characteristics , and engergies which facilite the ability to to acquiring other important entitites. When these resources are lost, threatened, or not gained when expected, this will cause stress and potentially lead to negative mental health or behavioral outcomes. Many of these negative outcomes result in a time-limited stress response with a brief, transient disruption of functioning followed by resilient adaptations. The proposed Resiliance Activation Framework illustrates the case where human capital , community capital , economic , or political capital are strong and provide adequate resources to support the pre-disaster adaptive capacities in the individual. However, more severe and persistent behavioral or psychological problems may result from disaster most notably, anxiety, depression, and Post Traumatic Stress Disorder . 17,20,21 These more debilitating problems often evolve after a period of chronic excessive stress that taxes the coping resource of the individual over time. To explain this process, the COR model would argue that persistent resource loss may lead to rapid resource loss cycles, which people are unable to reverse, and a downward spiral of behavioral health problems ensues. 22 Essentially, the initial loss of a valued resource increases the individual's vulnerability to further losses. For instance, a loss of tranportation and health may lead to lost job security, reduced self esteem, financial distress, marital and family pressures, and subsequent feelings of helplessness and hopelessness. Because the COR theory embraces so many aspects of individual, community, and socio-cultural entities, it has found considerable support after a wide variety of disasters, 20,[23][24][25][26] including the Deepwater Horizon Oil Spill. 13,27,28 To advance the application of the COR model in disaster recovery, it is essential to identify the specific resources necessary for activating or enabling critical resilience attributes. Thus far, it is generally well accepted that economic and social capital are essential to the resilience process. Specifically, economic resource loss, socioeconomic adversity, and/or loss of job opportunities have been consistently associated with the most severe, lasting, and pervasive psychological effects or the onset and course of depression, anxiety, and number of PTSD symptoms after disaster. 13,20,24,25,[29][30][31][32] Similarly, the convergence of data suggests that social deterioration [33][34][35][36] has also been associated with worse psychological outcomes. Testing the Resilience Activation Framework from diverse perspectives within the Deepwater Horizon Oil Spill consortia will enable the examination of these as well as other facets of the resilience processes to determine how they interact with individual attributes to facilitate resilience. --- Most people are inherently resilient or have the capacity to be resilient- Beginning in the 1970s, a distinct and well-established field of resilience research emerged from the discipline of developmental psychology, in which a number of investigators sought to identify the factors and traits that enabled children to achieve appropriate developmental milestones or avoid psychopathology even in the face of adverse circumstances or trauma. 2,37,38 Among the most durable findings from this scholarship was the normative response of children to be resilient, what Masten referred to as "Ordinary Magic," rather than the notion that resilience represented some unique representation of invulnerability. 2 Similar research developed among adult populations. 39 A short list of factors associated with an individual's ability to adapt to chronic and acute adverse circumstances emerged from a number of studies of children and adults, and includes personality factors , attitudinal factors , attachment factors , cognitive factors , and specific adaptation and coping skills . [40][41][42] Wright and colleagues refer to this scientific phase of the identification of resilience factors as the first of four waves of resilience research to date. 42 The subsequent waves of resilience research encompass an understanding of the complex processes that activate or facilitate resilience, an evaluation of the interventions that stimulate resilience, and more recently the epigenetic and neurobiological mechanisms of resilience activation. 5,6,43 Common to many of these studies is the notion that these individual traits contribute to adaptation and recovery responses when an individual adult or child is confronted with extreme stressors or "potentially traumatic events." 40 Masten 2 has distinguished the ways that such traits operate, either as moderators whose existence in a pre-disaster phase can help an individual withstand the effects of a traumatic event, or as risk-activated moderators whose latent characteristics are mobilized in response to a traumatic event, and which can in turn help the individual adapt or recover quickly from the stressor's effects. The Resilience Activation Framework illustrated in Figure 1 builds upon both the Conservation of Resources theory described above and the latency of resilience attributes that may be "activated." The COR theory is predicated on a deficit model, in that many of the factors that have been associated with increased mental health distress and psychopathology reflect a depletion, disruption, or chronic lack of access to critical resources or "capitals." In Norris and colleagues' 17 review of 160 disaster studies, the individual characteristics associated with poor mental health outcomes included female gender, low socioeconomic status, minority status, and prior psychological distress or disability, among others. The authors also note that an individual's lack of, or lost belief in his or her ability to cope or control outcomes, and having few social resources, are also associated with poor mental health. Silove and Steel 44 observe that disasters often lead to social disengagement, loss of social identity, and loss of meaning and existential coherence as social ties and institutions have been severed or destroyed. For example, a school-teacher who has been displaced by a disaster and who is unable to work now adopts the social role of victim or refugee, and loses the representation by self and others of the social role of teacher. These factors all reflect deficits, in which social, economic, or human capital has been diminished. The Resilience Activation Framework incorporates both the resource deficit model and the notion of latent resilience attributes. The framework suggests two pathways by which access to social resources can activate resilience processes: one in which the deficits are addressed by increasing the individual or community assets or facilitating access to them, and the other pathway in which the provision of formal or informal social resources enhances or activates positive adaptive traits. --- Community resilience attributes interact with individual resilience attributes -Community resilience can be defined as the enduring capacity of geographically, politically or affinity-bound communities to define and account for their vulnerabilities to disaster and develop capabilities to prevent, withstand, or mitigate for a traumatic event. 8,45 A community's capacity is dependent upon its access to human, economic, political, and social capital. 45,46 At a collective level, human capital refers to access to a healthy and capable population; economic capital involves access to money and other financial instruments and assets; political capital connotes access to both capable governance and to those institutions that influence the distribution of resources; and social capital may be defined as a community's access to local institutions and networks that promote collective cohesion and self-efficacy. As community resilience is conceived of as an ongoing process, much emphasis is placed on a community's ability to actively engage its population in developing capabilities through the enhancement of these four areas. In the pre-disaster phase, a community's latent resilience attributes would include the strength of the population's health ; the density and integration of formal and informal social networks and community-wide information pathways ; the identification of and hedging against community-wide risk using insurance and mitigation strategies ; and the effectiveness and efficiency of local government to achieve community consensus and equitably distribute and manage public resources . In the post-disaster phase, the activation of these resilience attributes could include the following: establishing access to quality health and mental health systems ; developing or capitalizing on emergent mechanisms to facilitate access to social networks, such as social media group work, or leveraging and integrating networks of trusted community-based organizations ; the establishment of equitable processes for facilitating productive public discussions and prioritization of collective actions ; and the ability to acquire and distribute public and private funds . Norris et al. 8 point out that community resiliency should be conceptually treated as distinct from resistance, wherein the resources available within a community are capable of mitigating any negative impact of a collective shock such as a disaster. Whereas effective community planning is intended to prepare for the generally expected short-term disasters such as floods, fires, and earthquakes, 47 community resilience suggests that a social system should adapt to and recover from the unexpected. 8,46,48,49 When community resistance to disaster fails, the result is the collapse of multiple systems of preparedness that produces a greater shock than a community is typically experienced with . 50 Thus in order to be truly resilient, a community needs to be able to adapt, evolve, or grow in ways that enhance disaster preparedness capability. 51 Enhancing community resilience then requires both the improvement of macro-level social factors such as education, employment, and population well-being while also facilitating strong and reliable partnerships between a diverse array of public, private, governmental, and nongovernmental organizations. 45 These partnerships can serve to mobilize community members during and after a crisis event so that the community population has access to critical information and necessary resources to facilitate preparedness and recovery. While there is general consensus that community resilience can be seen as the ability of communities to link individuals to key social resources, there is less clarity on how to measure these capacities and capabilities. 9 Building on the work of Norris et al., 8 Sherrieb and colleagues 9 propose that a general lack of quality secondary macro-level data on communities limits effective measurement to the areas of economic and social capital. In their community resilience index based on the measurement of economic and community social capital data available at the county level, they develop a useful measure of the relationship of resources to the process of resilience. Other measures, such as the "coastal community resilience index" used by the National Oceanic and Atmospheric Administration, the "community resilience program" used by the American Red Cross, or the "community resilience system" developed by the Community and Regional Resilience Institute are similarly limited by being location and disaster-specific. Advances in the measurement of community resilience, especially those theoretically modeled on communities' capacity to link individuals to vital recovery resources are focusing on the measurement of social networks that link individuals within a community to each other as well as to key institutions. Although no secondary data widely available to planners and policy-makers are available, rapid protocols for assessing the density of social networks and their capacity to mobilize resources in the event of a disaster are currently under development and promise to provide more accurate accounts of communities' capacity to improve individual well-being through the enhancement of community resilience. 52 4. Access to or engagement with social resources can activate resilient attributes-Most stress and disaster recovery models argue that people who have access to better social resources or social support are better able to resist the deleterious effect of postdisaster stress. 22,28,34,35 The proposed conceptual framework for resilience activation hinges on the ability of better social resources to activate resilience attributes toward maintaining pychological vitality, stability, and mental health as well as adequate physical health and well being. Using social support , as a potential activator of resilience, it is anticipated that family cohesion and warmth; strong social networks; and connection and bonding with others who are coping well in the post-disaster environment should enhance the resilience process, resulting in better behavioral outcomes. Social support could potentially activate resilience processes by providing knowledge and assistance for practical needs; helping with perspective taking for reasoning and problem solving; promoting positive emotions and attitudes associated with resilience ; facilitating adaptive coping behaviors; helping to regulate negative emotional states through providing respite; and/or helping to find a greater meaning or purpose in the situation. 29,53,54 --- Activation of resilience attributes takes place within the context of a sociocultural milieu-Exploring the cultural context of resilience among Gulf Coast communities is intrinsic to the success of public health interventions in promoting and activating resilience across the disaster prone region. 55,56 Early scholarship on human resilience sought to distinguish it from ecological resilience and pointed the way toward community-based resilience, but did little to parse out the role of culture. Adger 61 noted several key elements that separate biophysical and human resilience. Human institutions, he argues, are absent in ecological systems, and they offer human communities a persistent mechanism for coping with disruption. 61 These institutions, whether religious, ethnic, or legal, provide a means for individuals and communities to sustain resilient capacities and to pass that wisdom on to subsequent generations through social memory. 62,63 As human constructs, these institutions reflect cultural influences and are largely local in scale. Thus, they mediate how a community prepares for and responds to a disruption and activates its resilient capacities. From the community level, culture and ethnicity/race are prime mechanisms for enabling and perpetuating resilience. Important lessons learned in the aftermath of both domestic and global disasters have confirmed the pivotal role of culture in resource supply as well as redevelopment practices. Community-embedded institutions, such as faith-based organizations and cultural affinity groups, often serve as asset mapping agents, facilitating access to portfolios of resources. in a just-in-time culturally-tailored fashion. Over the past few years resilience studies have provided more insight into the cultural context. Communities with deep cultural and subsistence roots in places have demonstrated the capacity to "manage resilience" on the fly through adaptation. [64][65][66] Repeated hurricane strikes, along with other environmental disruptions, have impacted Louisiana's coastal minority communities over the past several centuries. Yet, these natural resource-based communities have persisted in the face of extreme environmental circumstances. [67][68][69] At the core of their adaptive success have been ethnic/cultural ties that provide essential networks through church and kin connections, and an enduring attachment to place that drove individuals' desire to stay and adapt as a cultural community. These linkages enable mobility, both economic and geographic, to cope with and rebound from disruption. Successful adaptation may require the extension of social institutions across ethnic lines and over long periods of time and this is possible at the community level. Furthermore, inherent resilience that pre-dates formal programs is rooted in local practices finely attuned to local conditions and enables communities to perpetuate themselves in place even without topdown efforts. 59,65 6. Individual, community and sociocultural milieu can be quantified or measured-In individuals, resilience in the face of disaster, adversity, or overwhelming disadvantage is a multi-faceted process. There are resilient people, resilient behaviors , and resilient outcomes. Thus, resilience has been studied as a personality or character trait, a process, and an outcome. Although the theory far out paces robust construct measurements, measures of personality characteristics such as self-efficacy 23 and selfreported resilience 73 have been associated with better post disaster mental health outcomes. 13,74 Promising measures for studies to test the Resilience Activtion Framework may also included those which assess various attitudes associated with resilience such as, optimism 75 and positive emotions, 53,54,76,77 which have also been able to distinguish between people with successful and unsuccessful adaptation after extreme stress. Resilient behaviors have been predominantly studied by measuring the efficacy of a person's coping efforts, distinguishing between the traditional notions of problem and emotion focussed strategies. 78,79 After disaster, problem-focused coping strategies are thought to have a greater association with resilient outcomes than emotion-focused or avoidant strategies. While this association is supported from both rational and theoretical perspectives, with the exception of a few studies 13,20,80 there is limited consistency in the disaster literature about which coping behaviors are better than others after disaster. This is most likely due to the many biopsychosocial factors associated with the coping process, the tendency for most people to use a wide range of coping strategies in the face of extraordinary challenges , and the fact that effective coping behaviors often vary with the changing post-disaster situational demands. Lastly, the Resilience Activation Framework does not presume that resilient outcomes are limited to the absence of mental illnes. Positive outcomes could include the presence of ongoing psychological vitality, good health, quality of life, family functioning, maternal bonding, or general well being. The measurement of social capital is typically divided into two approaches. Whole network analysis focuses on the interactions between people within a socially or geographically bounded group, such as a classroom or office. 81 Those using this approach hypothesize that the interactions occurring within the bounded space affect some outcome, in this case social resources in times of disaster. The method involves getting some measure of interaction between members of the whole network. The other approach is called personal or egocentric network analysis. With this approach, researchers do not think the outcomes are restricted to social influence within a socially or geographically bounded space. 82 Instead they see individuals as living within social contexts that vary in size, with people who of varying characteristics arranged around them in different ways. For linking individual and community resiliency, neither approach alone is ideal. A new approach being developed using an overlapping personal network approach where respondents from the communities provide personal networks using the typical method where a set of personal networks of respondents from a bounded space are merged by name and compositional characteristics to yield a whole network for the community. This approach is based on research that shows how some members of a whole network can accurately report on the structure of interactions within the whole network and charactertize the flow of resources within its structures. 83,84 From a socio-cultural perspective, proxy measures of resilience, such as demographic and economic change, have been used at the national and community scale, 57,58 but other evidence offers insight into adaptive capacity over long periods of time. Historical legal documents, for example, document the presence or absence of community resilience in the wake of disruptive events. 65 For example, after a 1930s oil spill destroyed their oyster beds, local oystermen capitalized on familial and cultural ties by going to work on their relatives' and neighbors' shrimp boats. Several methods exist for measuring such cultural historical resilience. One relies upon primary or secondary texts, including interviews with individuals who experienced disruption and participated in the response and recovery, or historical records, such as newspapers, local government body proceedings, and government accounts of how a community coped with hazard events. 59, 70-72. By tracing the continuation or disappearance of resilient practices, one can test whether or not a community is perpetuating its resilience. Another method to assess socio-cultural aspects of resilience is through the investigation of cultural consonance:the degree to which indivduals approximate, in their own beliefs and behaviors, prototypes for belief and behavior that are encoded in shared cultural models. This method incorporates a two-pronged approach, first, implementing cultural domain analysis, and later cultural consensus analysis. [85][86][87] Increasing understanding of the specific disaster-associated stressors, culturally shared histories and beliefs associated with adversity, and the contributions of their cumulative life circumstances will advance knowledge about how culture may inhibit or activate individual and community resilience, influence health, and improve quality of life across various settings. 88,89 --- Implications for Behavioral Health The integrated resilience research framework as described provides unique, transdisciplinary opportunities for behavioral interventions. Although the impact on future interventions are likely to be predicated on the anticipated research findings, the Resilience Activation Framework provides a roadmap for action that could potentially impact behavioral health intervention practice, policy and research. --- Impact on behavioral health intervention practice Communities living on this country's Gulf Coast have faced decades of interdependent challenges directly affecting their individual health and that of their communities: lack of preparedness against natural disasters and the impact of those disasters on physical and mental health well-being; persistent health disparities specifically related to chronic health conditions such as cancer and asthma in addition to birth outcomes such as preterm birth and low birth weight; and historical environmental contamination exacerbated by the aftermath of Hurricanes Katrina, Rita, and Isaac. While progress has been made in documenting those challenges, the solutions to date have employed narrow, "silo-driven" research designs, lacked a community-based participatory approach, and failed to produce sustainable ecological, system-driven solutions. In addition, previous studies of environmental disasters largely indicate that although the physical effects of environmental disasters are usually the major source of concern, psychological effects of these disasters can be more significant. 90 In general, disaster-related behavioral interventions have not yet fully benefited from a comprehensive integration of community context, assets, and "state of resilience." Timing and type of intervention activities affect frontline disaster behavioral health practice. To date, for example, most behavioral interventions have been implemented post-disaster, in most instances focusing on a single adverse mental health condition at the individual level. As depicted in figure 2, the effectiveness of behavioral interventions aimed at strengthening resilience is influenced by an individual's or community's capacity , their capability to activate those capacities, and ultimately the extent to which such interventions strengthen resilience, for example, as manifested in improved mental health. Hence, post-disaster interventions in isolation of assessing the state of the supporting attributes pre-disaster of the individual's or community's capacity to activate those attributes post-disaster are unlikely to improve mental health and consequently resilience in a sustained fashion. For instance, the efficacy of behavioral programs such as the Crisis Counseling Assistance and Training Program could potentially be strengthened long term by incorporating broader data -based elements of the Resilience Activation Framework. Specifically, post disaster CCP interventions such as community-based outreach and psycho-educational services could be enhanced by linking individual-level interventions to broader community resilience activities and partnerships that may serve to activate and sustain adaptive behaviors. This may be accomplished through emergent Long Term Recovery Committees that are perpetuated in a disaster's aftermath or through community coalitions developed in advance. The success of any behavioral intervention hinges on built-in scalability to the scope and type of hazard as well as the degree of community engagement in all aspect of the intervention-from design to evaluation. Furthermore, particularly in Gulf Coast communities, the extent to which an intervention is embedded in the local culture and utilizes existing assets will significantly influence both short-term effectiveness and longterm sustainability. These interventions should also consider the population vulnerabilities which might impede access to such interventions . Messages promoting such behavioral interventions should be developed with such vulnerabilities in mind. Behavioral interventions aimed at strengthening resilience in the context of disasters must transcend the traditional medical model and adopt a culturally sensitive, community-based approach as the preferred type of intervention. Beyond improving individual mental health, community-based behavioral interventions are uniquely poised to build on the characteristics a resilient community must have to "bounce back" from a disaster, promote what a community must do day to day to create these characteristics pre-disaster, and most importantly, increase a community's capability to "forecast" so that its members can be well-positioned for the next challenge. Targeting communities as the recipients of behavioral interventions has the important added advantage of fostering a more transdisciplinary approach to psychosocial health. For example, adopting a biopsychosocial model prenatally not only expands the spectrum of intervention to early development, but also the focus of the intervention to the family as a unit by promoting positive "influencers" such as, maternal warmth as a moderator of prenatal stress on child outcome. 91 Likewise, the extension of an anthropological model of psychosocial stress that focuses on the modifying effect of culture provides a promising avenue to address disaster-related stress in Gulf Coast communities where cultural context is likely to serve as an enabler of resilience at both the individual and community level. 85,86 --- Impact on behavioral health intervention policy The National Disaster Management System represents a top-down hierarchical approach to providing aid to communities with support requested from the Federal level by a Governor and subsequently delivered through state and local agencies to individuals in communities. The National Response Plan is composed of several Emergency Support Services outlining how post-disaster aid flows from the federal level to state and local agencies and ultimately to communities. 92 Behavioral health care is provided under ESF 8-Public Health and Medical Services. From a policy perspective, the plan stipulates that services are provided in response to a disaster or during a potential or actual emergency. This current construct hampers access to behavioral health interventions for communities such as those living on the Gulf Coast who have experienced successive trauma and need mental health support during the extended recovery phase rather than only immediately post-disaster. Superimposed on the lack of behavioral health care in the context of disasters is a fragile health system in general and that supporting mental health, specifically. To complement these limited resources especially in vulnerable populations, the National Academy of Sciences proposed a conceptual model to build community resilience through private-public collaboration. 93 The model represents a paradigm shift in several key areas and articulates a set of guidelines and strategies which are reflected in the proposed Resilience Activation Framework . Key among the strategies fostering privatepublic collaboration are the integration of capacity building within the community , employing a community-based systems approach, strengthening resilience through education and training in partnership with educational institutions, and creating flexible funding and resource allocation policies. The underlying premise implied by this guidance is that to be effective and have sustained positive health outcomes, behavioral interventions should be accompanied by private-public partnerships aimed at activating community capacity, and targeted education and information dissemination. These "resilience-focused" private-public partnerships may represent a desirable change in policy since those can serve as both a deployable portfolio of assets in the pre-disaster period as well as a sustainable resource during a prolonged recovery stage. --- Impact on behavioral health intervention research In its 2011 publication on "Building Community Disaster Resilience through Private-Public Collaboration" the NAS concluded that, "A nation is resilient when it is made up of resilient communities." 93 Integral to achieving this goal is assuring disaster behavioral health interventions are based on the most contemporary science. Among the recommendations for future research by NAS are focus areas highly relevant to the proposed Resilience Activation Framework: research that results in quantitative risk and outcome markers, projects which strengthen community resilience, and document best practices. In addition, advancing the science base by producing nationally applicable data examining the interdependence of vulnerability and resilience has a high likelihood of providing behavioral health practitioners with tailored, evidence-based tools. Given the multiple levels at which the RAF operates, these tools could potentially guide the systematic outcome studies of a wide range of interventions designed to enhance resilience or related capacities in individuals and families in crisis. Depending upon the type of disaster involved, this could include, but not be limited to enhanced, outcome studies of hardiness, stress inoculation or learned optimism training; social support; well-being therapies; or other psycho-educational interventions. Data from the RAF model could also lead to the development of new rationally based interventions with diverse populations within the context of their culture, taking into consideration community, economic and political resources as well as the specific type of disaster. Importantly, as guided by the model, these therapies, psycho-educational interventions, and messages would need to be tailored to specific populations including infants, children, adults, older adults, as well as those with functional access needs and the burden of mental and substance abuse challenges. --- Conclusion In the aftermath of the Deepwater Horizon Oil Spill the Substance Abuse and Mental Health Services Administration and the National Institute of Environmental Health Sciences at the National Institutes of Health embarked on a series of collaborative and integrated research projects to increase understanding of the mechanisms by which access to social resources activate and sustain resilience capabilities after disaster. The Resilience Activation Framework was developed by the participating research consortia to serve as a unifying heuristic in which to frame the authors' collective research, to strengthen the interdependency of the supporting research projects, and to provide a common language in which to assess the results and implications for both policy and interventions. --- Resilience Attributes at Community and Individual Levels --- Conceptual Framework of Resilience Activation

A number of governmental agencies have called for enhancing citizen's resilience as a means of preparing populations in advance of disasters, and as a counter-balance to social and individual vulnerabilities. This increasing scholarly, policy and programmatic interest in promoting individual and communal resilience presents a challenge to the research and practice communities: to develop a translational framework that can accommodate multi-disciplinary scientific perspectives into a single, applied model. The Resilience Activation Framework provides a basis for testing how access to social resources, such as formal and informal social support and help, promotes positive adaptation or reduced psychopathology among individuals and communities exposed to the acute collective stressors associated with disasters, whether manmade, natural, or technological in origin. Articulating the mechanisms by which access to social resources activate and sustain resilience capacities for optimal mental health outcomes post-disaster can lead to the development of effective preventive and early intervention programs.

INTRODUCTION In October 2008, the Commanding General at Fort Carson, Colorado, initiated a task force to investigate an apparent clustering of homicides and attempted homicides among soldiers currently or recently assigned to the Army installation. The Office of the Army Surgeon General and the U.S. Army Public Health Command coordinated a multidisciplinary epidemiological consultation . 1 The U.S. Army Public Health Command Behavioral and Social Health Outcomes Program conducted the investigation to examine rates and trends in violent deaths involving Fort Carson soldiers ; identify risk factors associated with the violent deaths; assess the adequacy of behavioral health programs, resources, and social support for soldiers in the units studied; and recommend strategies to enhance current programs and reduce the installation's incidence of violent death. This article summarizes the analytic methods and findings, with a focus on the mixed-methods analytic approach used to study a complex behavioral issue at the community level. The impetus for the investigation was 8 homicides allegedly perpetrated from late 2007 through October 2008 by 6 Soldiers assigned to the same brigade combat team . A BCT is a modular, combined arms force capable of self-sustaining offensive, defensive, stability, and civil support operations. Its core mission is to close with the enemy by means of fire and maneuver to destroy or capture enemy forces, or to repel enemy attacks by fire, close combat, and counterattack. A BCT can fight without augmentation, but it also can be tailored to meet the precise needs of its missions. A typical BCT has 3,000 to 5,000 soldiers. An additional 6 homicides or attempted homicides were allegedly perpetrated by soldiers from Fort Carson between 2005 and 2008. The investigation addressed the social environment in which they were perpetrated, and potential risk factors and experiences that may have influenced the homicide rate in this population. The investigation focused on common factors among homicide perpetrators, rates of violent or criminal behavior at Fort Carson, whether enlistment waivers were associated with any increase in violence, unique BCT characteristics that could account for increased aggressive behavior, and evidence of any relationship between deployment experiences and risk for aggressive behavior. The USAPHC scientific advisory committee determined this EPICON was a required public health investigation. Under the provisions of Army Regulation 40-5 , 2 USAPHC is the designated public health authority for the Army. Institutional Review Board approval was not required. Participation in surveys, focus groups, and interviews was optional. The views expressed herein are the views of the authors and do not reflect the official policy of the Department of the Army, the Department of Defense, or the U.S. government. --- METHOD A mixed-methods approach, using quantitative and qualitative, individual, and population-level assessments, was used. Six study arms were carried out: index case analysis, confinee interviews, installation-level trend analysis, retrospective cohort analysis of the index BCT and a comparison BCT, soldier focus groups and leadership interviews, and development and administration of an aggression risk factors survey of current index BCT soldiers. --- Index Case Analysis Index cases were defined as any soldier assigned to Fort Carson charged with homicide, attempted homicide, or accessory to homicide from January 1, 2005, through October 30, 2008. Fourteen soldiers were identified as index cases for the analysis. Demographic, medical, administrative, deployment, and legal information on the index cases was obtained. These data allowed for detailed examination of medical diagnoses, negative behaviors, misuse of alcohol/illicit drugs, administrative and legal actions, and deployment experiences. --- Confinee Interviews Interviews were conducted with 9 of 14 index cases who were incarcerated and consented to be interviewed during the EPICON. Since many confinees were still involved in the judicial process or pending an appeal, measures were taken to ensure confidentiality and ethical treatment. All interviews were conducted by the EPICON team social worker/forensic psychiatrist. A standardized script and series of questions were developed and used during the interviews. Questions were drafted so as NOT to ask about specific alleged crimes. At the beginning of each interview, the interviewers identified themselves, emphasized they did NOT want to know anything about the index case's alleged crime, and described the intent of the interview was to obtain better understanding of the index case's experiences and general thoughts regarding soldier support, deployment experience, and command climate in order to improve things in the Army. The index cases were told the interview was voluntary, they could refuse to participate outright and refuse to answer any particular question, and/or they could terminate the interview at any time. All interviews were carried out in private. In two instances, the confinee's legal counsel was present in the interview. Most interviews were 60 to 90 minutes. --- Installation-Level Trend Analysis A population-level analysis was conducted to identify trends of risk factors related to aggression and violence in the Fort Carson community. When possible, data from Fort Carson were compared with other "power-projection" installations and/or the overall Army to assess whether observed trends were common or unique to Fort Carson. Installation-level data included: major crime charges and/or arrests ; suicides; Reintegration Unit Risk-Inventory measures that screen for high-risk behaviors and attitudes affecting military unit readiness and individual well-being; rates of mental health diagnoses; and mental health service utilization . --- Retrospective Cohort Analysis of Index and Comparison BCTs A retrospective cohort analysis was conducted to assess differences in the rate of exposures and mental health outcomes between the index BCT from which the majority of the perpetrators came and another Fort Carson BCT with a similar number of Iraq combat-deployments. To assess the potential cumulative effect of deployments and the pace of training for combat on the outcomes of interest as well as the effect of enlistment waivers, demographic, medical, deployment, and associated enlistment records were obtained for 20,737 soldiers assigned to the two BCTs from 2003 to October 2008 . Two types of comparative analyses were conducted: an overall comparison of data from all soldiers within the index BCT to another BCT at Fort Carson and a time phased comparison before, during, and after deployment for all soldiers who previously deployed with the BCTs. T-test and z-test statistics were calculated to estimate whether mean values and proportions within and between the two populations were significantly different . Adjusted relative risks were calculated, using generalized linear mixed modeling to account for the hierarchical nature of the data, to assess the association between enlistment waivers and subsequent negative behavioral outcomes . --- Soldier Focus Groups and Leader Interviews Focus groups were conducted using semistructured interview guides with soldiers across rank groups and battalions in the index BCT to obtain a detailed understanding of current perceptions and attitudes. BCT leadership assisted with recruitment by randomly selecting soldiers to participate. Before beginning, all soldiers were provided an overview of the purpose by the facilitators and had the option to decline to participate. Fifty-nine focus groups were conducted anonymously with 402 soldiers . Most groups consisted of 8 to 10 soldiers; however, group sizes ranged from 2 to 15 soldiers. Groups were conducted with ranking soldiers. Conducting groups with junior-and senior-enlisted soldiers together can be problematic because junior enlisted are less likely to report opinions differing or contradicting senior enlisted, and junior enlisted may be less likely to report information that could result in trouble for themselves or fellow soldiers. All groups were asked similar questions pertaining to awareness and utilization of BH resources, command climate, discipline standards, quality of soldiers currently joining the Army , perceptions of the increase in homicides, and considerations for change . BCT leaders and mental health service providers were interviewed individually or in small groups to ensure their information was completely captured and to ensure their influence would not bias soldier groups. Data was analyzed by two analysts, using the constant comparison method, 3 whereby major themes were extracted and compared across rank groups and battalions to determine whether there were any similarities or differences in the strength and interpretation of the group composition themes. --- The Aggression Risk Factors Survey The ARFS was developed for this EPICON to assess the experiences, attitudes, and climate of the index BCT population with whom many perpetrators served. Previously, validated scales were included, to the extent possible. Domains for the questionnaire items were based on main contributory factors of criminal behavior, including mental illness, criminal/ violent history, alcohol abuse, 4 and antisocial attitudes. 5 Attitudes toward noncombatants and improper behaviors during deployment that could indicate the construct of antisocial/ social attitudes were measured using a scale adapted from the U.S. Army Mental Health Advisory Team. 6 Demographic and military characteristics were assessed. A modified version of the Revised Conflict Tactics Scale was used to assess minor and severe physical aggression among both married and single soldiers. This scale was used according to strict licensing agreements. 8 The Post-Traumatic Growth Inventory 9 was included to quantify positive experiences following deployment such as spiritual change, personal strength, relating to others, appreciation for life, and new possibilities. Population responses to a 15-item combat experience survey 10,11 were categorized into tertiles to include a third of the deployed population within each level to approximate combat intensity: low , moderate , and high num-ber of combat experiences. Logistic regression modeling, adjusting for potential covariates using stepwise backward deletion of the least significant factors, was used to assess the association between cumulative combat experiences and negative behavioral outcomes . --- RESULTS --- Index Case Findings Of the 14 index cases, 10 involved Fort Carson soldiers charged with homicide, 2 charged with attempted homicide, and 1 charged as an accessory to homicide. One individual committed homicide followed by suicide, thus was never charged. Commonalities identified among the index cases included: military unit of assignment, deployment/combat exposure, military occupational specialty, and behavioral risk factors. Ten of 14 index cases were assigned to the index BCT, and 6 were assigned to a specific infantry battalion within the index BCT. Twelve of 14 index cases, including all 10 of those assigned to the index BCT, were deployed at least once to Iraq and were assigned to a unit that experienced higher levels of combat intensity than other units deployed from Fort Carson as indicated by a comparison of combat casualties. Six of 12 index cases who deployed returned home early from deployment [for combat injuries , suicide attempt , suicidal ideation , misconduct , and family reasons ] and did not receive standard Army reintegration training. This training is completed after deployment, but before soldiers going on postdeployment leave, and consists of multiple classroom sessions intended to assist soldiers in their transition from combat to home and to help identify individuals at risk for subsequent medical and behavioral problems. Five cases received an enlistment waiver for otherwise disqualifying conditions [related to prior criminal or drug/alcohol related charges and medical conditions ]. Behavioral risk factors were prevalent among index cases, including alcohol/substance abuse history , mental health diagnoses , and criminal activity while in the military . Based on aggregate population data comparisons, before perpetrating the alleged crimes, index cases were at higher risk for clustering of negative behavioral outcomes compared with the overall index BCT. Fiftyseven percent of index cases had documentation of all 3 major risk factors, significantly more than soldiers from the BCT completing the survey . Index cases were more likely to exhibit both criminal behavior and at least one other negative behavioral risk factors than other soldiers who deployed with the BCT. --- Confinee Interviews Most confinees interviewed reported significant combat exposure, and more than half reported witnessing unethical conduct while in Iraq. Upon returning home, they reported struggling with the consequences of what had occurred in Iraq-both psychologically and morally. They felt "naked"/ unsafe without a weapon and consequently carried weapons around with them. Many reported drinking, taking illegal drugs, or misuse of prescription medications as a coping mechanism. Many of the confinees reported efforts to selfmedicate only complicated their problems and, in some cases, made getting help more difficult. Many reported not transitioning well from combat to home-particularly when it came to shifting roles and conventions. As one confinee put it, "There [in Iraq] we were the law; here the cops are the law." The confines reported mixed support from command and peers for getting help, but on the whole, command and peers did not promote help-seeking. In some cases, leadership verbally supported help-seeking, but their actions contradicted their message and ultimately discouraged help-seeking. The perception of the confinees, on the whole, was that they came home to a BH system overwhelmed, severely shortstaffed, fragmented, and poorly organized. To the confinees who did engage the BH system, the system seemed chaotic, sporadic, and uncaring. --- Installation-Level Trends Although the rates of arrests for major crimes increased across the Army and comparison installations from 2003 to 2008, the rate of arrests for major crimes was higher at Fort Carson than comparison installations in 2007 and 2008 . The average number of murders doubled from 2 to 4 per year at Fort Carson from 2003-2006 to 2007-2008, but murder remained a rare event in this population of nearly 18,000 soldiers. Murder rates based on small counts may reflect random variation rather than statistical significance. --- Combat Deaths and Experiences Based on combat death data, soldiers deployed with the index BCT generally experienced greater combat intensity than soldiers deployed with the comparison BCT . As observed in the retrospective cohort study, soldiers in the index BCT experienced higher levels of postdeployment mental health problems, traumatic brain injury , and positive tests for illicit drug use than soldiers in the comparison BCT . Based on responses from the ARFS, increasing levels of self-reported combat intensity were significantly associated with increased odds for self-reported aggression, problematic alcohol use, criminal convictions, mental health problems, and physical altercations with a significant other . --- Drug and Alcohol Abuse Soldier focus groups revealed a strong theme of alcohol/drug use to "self-medicate"; soldiers perceived inconsistent discipline for substance abuse, positive drug tests, and misconduct. On the ARFS, previously deployed soldiers reported higher levels of problematic alcohol use than soldiers never deployed. Cohort data revealed many soldiers in both the index and comparison BCTs who tested positive for illicit drugs never received required Army Substance Abuse Program screening . --- Enlistment Waivers The proportion of soldiers receiving enlistment waivers of any type for otherwise disqualifying conditions increased from 2003 to 2007 across the Army and among soldiers assigned to both BCTs. No difference was evident, however, in the proportion of soldiers with moral waivers between the index and comparison BCTs. Soldiers from both BCTs granted a waiver for alcohol/drugs or serious nontraffic offenses were approximately 2 to 3 times more likely to later test positive for illicit drugs and were significantly more likely to be discharged from the Army for misconduct and/or military violations . Examples of serious nontraffic offenses include conviction or adverse disposition for carrying of weapon on school grounds; an act of violence including threats against any school faculty members; domestic battery/ violence not resulting in a qualifying Lautenberg conviction 12 groups. Junior-enlisted soldiers from the index BCT reported being viewed as "weak" or labeled "bad soldiers" by peers if they sought mental health care or received mental health diagnoses. Some junior-enlisted soldiers reported during focus groups, "Senior NCOs were the main ones who create stigma." Senior-enlisted soldiers and officers reported concerns that seeking mental health care would negatively impact their career. One senior-enlisted soldier reported, "If you go to see someone, you're committing [career] suicide." Peer perceptions and personal factors were reported at least as important in perpetuating stigma as leadership issues. The junior-enlisted groups expressed fear of retaliation for seeking mental health care . One junior-enlisted soldier reported, "the mentality here is that you deal with it." They also perceived a lack of confidentiality when using military providers because of information being shared with/ by unit leaders. Senior-enlisted groups reported concerns seeking mental health care would reflect negatively on their leadership abilities. One senior-enlisted soldier reported, "seeking help is even more difficult for senior enlisted because others think they can't lead." --- DISCUSSION Soldiers allegedly involved in crimes related to homicide at Fort Carson were, in retrospect, at risk for engaging in violent behavior based on a clustering of known risk factors for violence. These included prior criminal behavior and psychopathology . Similar results have been reported among civilian populations. [13][14][15] Nearly 80% of the alleged perpetrators had documented alcohol/drug abuse problems, yet less than half of those individuals had evidence of receiving alcohol/drug treatment. Over 80% of those with alcohol/drug abuse problems were charged for criminal activity or misconduct while in the military , by civilian law enforcement or the Uniformed Court of Military Justice, and, therefore, were at particularly high risk for continued criminal and/or violent behavior. The index BCT, however, did not have a higher proportion of individuals with psychopathologic risk factors than the comparison BCT; thus, those risk factors alone do not entirely explain the apparent clustering of crime in this population. Alleged perpetrators were clustered within a single BCT at Fort Carson and within a particular infantry battalion. No demographic or individual level risk-factor characteristics of the two BCTs or infantry battalion within the index BCT accounted for the observed difference in criminal behavior. The index BCT and the infantry battalion experienced significantly higher levels of combat intensity than the comparison BCT and the comparison battalion. Data suggests a possible association between increasing levels of combat exposure and risk for negative behavioral outcomes. These findings are consistent with recent research on combat exposure and subsequent behavioral outcomes among soldiers. [16][17][18][19][20] One model of aggression 21 suggests aggressive impulses are expressed as overt aggressive behaviors mitigated by "amplifiers" and "attenuators," which increase and decrease the probability of aggressive behavior, respectively. In the present study, amplifiers could include combat experiences/ intensity and stigma with seeking help for mental health problems; attenuators could include the close social structure of military units, availability of medical and mental health care, and unit cohesion. In the context of this framework, the findings might suggest soldiers in the index BCT and battalion experienced more "amplifiers" and fewer "attenuators" than soldiers in other units, perhaps driven by differences in combat experiences/intensity and stigma related to seeking care for mental health problems. Analysis of enlistment waiver data did not demonstrate a significant association between waivers and the clustering of homicide in the index BCT. Although 3 of the index cases received an enlistment waiver for moral issues, there was no difference in the proportion of soldiers with moral enlistment waivers between the two BCTs. Approximately 14% of total U.S. Army accessions were granted moral enlistment waivers during 2007-2008 . Soldiers from the index and comparison BCTs, however, who received enlistment waivers for alcohol/drugs were more likely to be discharged from the Army for misconduct and/ or military violations. Similar character traits may exist between developmental pathways leading to aggression 22,23 and the types of misconduct covered by moral enlistment waivers granted to U.S. Army recruits. If true, soldiers with known criminal activity may represent a population with higher preexisting risk factors for negative behaviors, including substance abuse and propensity for rule-breaking behavior. Preexisting risk factors may play a greater role than exposure to combat stress in the expression of antisocial behavior, 24 and the existence of multiple comorbid risk factors in individuals may pose the greatest risk for potential expression of violent behavior. 13,25 Soldiers exposed to a multitude of environmental and occupational stressors are at increased risk for development of mental health problems. 26 The diathesis-stress model, which postulates stressful situations can activate a diathesis, transforming potential biologic predispositions into the presence of psychopathology, 27 may explain how preexisting factors and events experienced in childhood/early life 28,29 can be triggered by stressful situations and manifested as negative behavioral outcomes 30,31 among soldiers during and following intense combat experiences. An increase in the proportion of soldiers with a high risk for negative behavioral outcomes, in conjunction with unit and/or environmental risk factors, may increase overall population risk, resulting in a population with a higher likelihood of violent outcomes. Based on these results, it is plausible that multiple factors converged to increase overall population risk in the index BCT as a function of increased risk among individuals in combination with unit/environmental factors, thus increasing the likelihood for a clustering of negative behavioral outcomes within the BCT. This EPICON was conducted under a compressed 90-day schedule. Some limitations should be considered when interpreting the results. Foremost, risk factors identified in the 14 index cases may not be representative of all Army homicide perpetrators. The results from the BCT comparison are based on characteristics of soldiers in two units, one of which experienced a unique set of deployment circumstances and an unexpected clustering of violent crime. Results from the comparison study, focus groups, and survey are likely not representative of the overall Army. Information collected through surveys and focus groups is based on self-reported measures and perceptions, and although soldiers were assured their responses would be kept confidential, we cannot guarantee all soldiers answered completely and honestly for fear of repercussion or stigmatizing beliefs. The cross-sectional nature of the survey data does not allow for making causal inferences. Comparison data that could provide further context for all measures was not available at the time of the study. It was not possible to obtain the percent of U.S. Army soldiers returning from deployment early that completed reintegration training. Typically, the completion status of reintegration training is tracked for all soldiers returning from deployment by their respective units; however, it is less clear whether completion status is tracked as individual soldiers return from deployment early. Each Army installation is unique and caution should be used when interpreting installation comparisons. In spite of these limitations, this EPICON represents a unique mixed-methods approach to studying complex behavioral issues at the community level and the most in-depth recent examination of violent crimes in an Army unit. Before the conclusion of this EPICON, Fort Carson started addressing many issues identified. Fort Carson's Evans Army Community Hospital increased staffing and implemented BH outreach and mobilization teams to address many issues described, and also provided dedicated BH assets at the BCT level. Other ongoing/current actions to address issues identified include: enhanced reintegration training for redeployed soldiers; mental toughness training for deploying units; increased utilization of installation prevention team to help Command identify trends, soldier care issues, and treatment options; and innovative efforts to improve the Soldier Readiness Processing process by using screening methods that overcome soldiers' reluctance to truthfully report symptomology. Although not conclusive, the findings suggest a combination of individual, unit, and environmental factors converged to increase population risk in the index BCT, which increased the likelihood for clustering of negative behavioral outcomes. Accumulated risk based on individual predisposing factors may increase overall population-level risk for negative out-comes. The overall risk is best impacted by population-based mitigation programs, while maintaining strategies to effectively identify and intervene with individual soldiers. Mitigating strategies are suggested, which decrease both individual and population-level risk, such as improved screening and case-management to identify and follow-up with high-risk soldiers and units; elimination of barriers to substance abuse and mental health treatment; expedited processes for providing treatment and/or military discharge when appropriate; enhanced resources/training for small-unit leaders; and improved social support programs for soldiers and their families.

In response to an apparent clustering of homicides at Fort Carson, Colorado, the U.S. Army Public Health Command (formerly the U.S. Army Center for Health Promotion and Preventive Medicine) Behavioral and Social Health Outcomes Program conducted a multidisciplinary epidemiologic consultation to identify factors contributing to violent behavior among soldiers at Fort Carson. This article summarizes the findings of the epidemiologic consultation report as provided to the Secretary of the Army and the Fort Carson Senior Mission Commander and released in its entirety publicly July 2009 and elaborates on the mixed-methods analytic approach used to study a complex behavioral issue at the community level. To aid in answering the key study questions, six study arms were designed and carried out: (1) index case analysis, (2) confinee interviews, (3) analysis of installation-level trends, (4) retrospective cohort analysis, (5) soldier focus groups and interviews, and (6) aggression risk factors survey. Although not conclusive, the findings suggest a combination of individual, unit, and environmental factors converged to increase the risk of violent behaviors, which made clustering of negative outcomes more likely.

Introduction Religion is something sacred and important for every human being on earth. The inevitable thing is, in this world, every group has its religion which they have believed from generation to generation or the result of a change of mind. Differences in religion can be seen in the reality that existed in the past and present . Each religion also has different teachings, principles, norms, and laws in the procedures for worship as well as its leadership structure which are the characteristics and personality of the people themselves . He explained that the founders of religions and followers and adherents of religion certainly come from various social backgrounds from various class strata. Because these groups have different functions, thereby receiving different rewards from society, they also have different attitudes and values. Different conditions and lifestyles have given rise to diverse views, needs, responses, and motivational structures. Therefore, the diversity of groups in society will reflect different religious needs . Like Indonesia, religious life in the Indonesian nation, in its simplest form, has grown and been rooted since ancient times. The fact in history is that the growth and development of adherents of various religions whose spread gives different patterns from one region to another, in general, the pattern of relations and social arrangements between adherents of different religions also varies, depending on the degree of mixing between adherents of different religions developed . The major religions spread across Indonesia, such as Hinduism, Buddhism, Christianity, and Islam, must be fostered and developed to be more orderly and managed according to their respective teachings. Because when a religious group mixes with other religious groups, it will cause the birth and spread of ideas and values that influence human actions. This influence means a religion will influence the social structure and vice versa . In Aceh, inter-religious relations have long existed. However, what is unique is that Aceh is dominated by only one religion, Islam. While other religions, only a small percentage of the people of Aceh. Thus, the rules and norms that apply in people's lives are certainly more Sharia and Islamic. Those rules could lead to the government's tendency to enforce the law. Other religions that have contributed to building the people's social life of the People of Aceh are adherents of Hinduism, Buddhism, and Christianity. In Islam, they are called "Kafir Zimmi". Namely, people who are non-Islamic and live in areas where most Muslims are Muslim and have agreed to the provisions set by Islam. For example, they have paid tribute . --- Discussion --- History of Chinese Arrival in Aceh Aceh has been known since the beginning of the formation of the international traffic network . Aceh, located at the tip of Sumatra, has previously had splendor and fame, so it became the attention of traders and religious broadcasters from India, China, and the Middle East. Regarding --- Journal of Islamic History and Manuscript Volume 02, Number 01, January-June 2023 civilization or the form of the kingdom that existed on the tip of the island of Sumatra at the beginning of the arrival of Islam, there were already two kingdoms that were already established and had high civilization . These kingdoms played an important role in Sumatra and the Malacca Strait, especially in defending their territory from enemy attacks. The kingdoms were Lamuri and Samudra Pasai. The Kingdom of Samudra Pasai was also called Parsa, which the Chinese called Tashi. About the name Lamuri, there are lots of spellings. Marco Polo called it Lambri. Some call it Ramini, Ramni, and Arabs call it Lamberi. At the same time, the Chinese called it Lan-li, Lan-wuli, and Nanpoli . The name of the Lamuri Kingdom was mentioned many times in Chinese records. The oldest Chinese news was from 960 AD, which mentioned the name Lan-li, where Persian envoys who returned from China after 40 days of sailing could stop over. They waited for the cool season to sail again to their home country . Then Chau-Yu-Kwa, in his book Chu Fan-Shi, published in 1225 AD, stated that among the San-fo-ts'i colonies included Lan-Wwu-li,, which was most likely Lamuri. King Lan-wu-li was said not to be a Muslim, yet his palace had two reception rooms. If a person departed from this country in the northeast monsoon, he would arrive in Ceylon within 20 days. In 1286, Lan-wu-li and Su-wen-ta-la sent envoys to China and stayed there while waiting for the return of Kublai Khan's expedition from Java . Other records at the beginning of the Mongol dynasty in China showed several Sumatra kingdoms, such as Samudera Pasai, Lamuri, Tamiang, Peureulak, and Haru. The Samudera Pasai Kingdom began to have relations with the Mongol Dynasty in 1282. That year, the ruler of Pasai established relations with China through a Chinese envoy who returned from South India and stopped at Samudera Pasai . Meanwhile, the Lamuri Kingdom sent envoys to China in 1286. The Ming dynasty book explains that in 1405 AD, a seal and a letter were sent to Lam-bu-li in 1411 AD. Klantan and Cail envoys visited, then returned with the Cheng-Ho expedition . Cheng-Ho's expedition occurred during the Ming Dynasty . At that time, Samudera Pasai and China had established peace and trade relations . These rulers sent ships and gifts to one another. In 1430, when Cheng-Ho brought gifts all over the country, Lamri also got a share. The gifts were not sent for the first time because the bell named Cakra Donya bears Chinese and Arabic inscriptions and is marked with the year 1409 AD . This giant bell is made of bronze with a height of about 1.25 meters and a width of 8.75 meters . The bell was brought to Banda Aceh during the conquest of Samudera Pasai, conquered by Sultan Muhgayat Syah, the first Sultan of the Kingdom of Aceh Darussalam, in 1524 . It is recorded that Cheng-Ho made three visits to Samudra Pasai, namely in 1405, 1414, and 1430. During his second visit, Cheng-Ho witnessed the political conflict that occurred in Aceh. Cheng-Ho's arrival at this time was recorded in the history of the Ming Dynasty as well as the conflict with the Samudra Pasai Kingdom. When this political dispute occurred, Nahriansyah, the daughter of Sultan Zainal Abidin, was in power. A group of people who wanted to overthrow this female leader also attacked Cheng-Ho and his subordinates. However, the people of Samudra Pasai and Chengho's colleagues put up a fight. They succeeded in arresting Iskandar, the leader of the Samudra Pasai rebellion, and brought it to China . --- This goodwill trip established good trade and business relations between the Chinese ethnicity and the people of Aceh. Then, Chinese ethnicity began to arrive with more entourage to form groups or settlements in the coastal areas. However, the largest migration was recorded during the Dutch colonial period. --- Description of Research Location --- Geographical Location Gampong Peunayong is one of 11 Gampongs under the scope of Kuta Alam District, Banda Aceh City. This village is approximately 36.3 ha/m2 in area. The average height is 0.80 M above sea level. Geographically, the location of Gampong Peunayong is bordered by: a. To the north, it is bordered by Gampong Mulia. b. To the south, it is bordered by Gampong Kuta Alam. c. To the east, it is bordered by Gampong Laksana. d. To the west, it is bordered by Krueng Aceh, Kuta Raja District . The mixing of religions in one village has been going on for a long time. Moreover, until now, they still live contiguously. In terms of places of worship, every religion has its place of worship. In this village, there is a mosque as a place of worship for the Muslim community and a monastery as a place of worship for the Chinese Chinese community. Even so, all people can worship properly according to their respective religions. --- 1.1 --- The Response of Acehnese to the Chinese Ethnicity As social beings, humans need other people for sure. Therefore, humans must mingle with those around them because they cannot live alone. For example, the socialization relationship between neighbors, with social interaction between neighbors, will make it easier for humans to overcome problems around them that need help from other humans. In terms of keeping harmony between the two ethnic groups, it can be seen in their daily relationships. We can see how the Chinese ethnicity and the people of Aceh interact. Their mix is quite harmonious in a way that does not interfere with each other. The Acehnese and Chinese ethnicity in Gampong Peunayong live properly like people in other areas . Inter-religious or ethnic life in Aceh, especially Gampong Peunayong, should be a role model for other regions to emulate so they don't discriminate against minorities. Life on Earth is very short. If we treat others badly, how will we be held accountable in the afterlife . The response from the Head of General Affairs and Planning for Gampong Peunayong towards Chinese ethnicity was also quite good. It was noted that there had never been a fight motivated by differences in religion and ethnicity. The problem that never happened was a fight between neighbors. Because the people of Gampong Peunayong spend more of their daily lives at the market to trade, small problems often arise . For example, a shop next door between Chinese and Acehnese is known. Chinese are so disciplined and firm in trading. They do not mix personal matters when trading. One day, a shop occupied by Acehnese had a customer arrive and park his fourwheeled vehicle by taking the shop's parking lot occupied by Chinese. So there was a fight, and the matter had to be brought to the Gampong apparatus. Fortunately, these problems can be resolved by deliberation . Problems often arise among Chinese ethnicity themselves. However, Chinese ethnicity often solves their ethnic problems in the church and place of worship. Some were completed by the Gampong LINMAS division because 18 problems can be solved in the village. However, there was once a problem with Chinese ethnicity, and they took it to the police. However, the police returned the problem to the Gampong apparatus to be resolved . In September 18, 2018). When asked about the problems that had occurred, he explained that problems that had arisen among the people of Aceh, between Chinese ethnicity and Acehnese and among Chinese themselves, were resolved by Gampong officials such as Geusyik and Tuha Peut according to custom. This problem is related to community life and Gampong problems, such as disputes between shops . Because according to him, regardless of religion and ethnicity, they are still counted as residents of Gampong Peunayong . If the Chinese have religious problems, they will be resolved at church or gatherings. Likewise, if we have problems regarding religion, they will be resolved by themselves at the mosque. And the Chinese ethnicity has been like that from the beginning until now. It is just that their internal problems are rarely seen outside, meaning they are rarely exposed in non-Chinese society . Apart from that, in Gampong Peunayong, said Imam of the Mosque, there had never been any clashes between ethnic groups except between individuals in the life of fellow neighbors. Apart from that, so far there has never been a serious problem. Namely, the problem that brought caused ethnic groups to experience a shock to live together. In fact, according to him, there has been a feeling of mutual trust between the Chinese ethnicity and the people of Aceh . One of the proofs is that some Chinese traders place Acehnese workers as cashiers and look after their shops when they are not there. As is known, the Chinese people rarely involve other people in finance for their trade. Usually, they place their siblings or children . Talking about comfort in society, he is comfortable and likes to mingle with Chinese ethnicity. There is no particular problem that disrupts the life of the Acehnese people. Regarding maintaining harmony in life, the tips used by the Gampong were to "To you is your religion, and to me is my religion," he added. Even so, in Gampong affairs, the Chinese must join Acehnese society with an Islamic theme . Regarding religious activities, such as during Friday prayers and celebrations of Islamic holidays, the Chinese respect the Muslim agenda by closing shops during Friday prayers, etcetera. When celebrating Chinese holidays, the people of Aceh also appreciate it, but it doesn't do the same because Chinese holidays only take place in their church. So far, Mr. Zubaili has not been disturbed by the inter-ethnic life in Gampong Peunayong . Safrizal, a bookseller in Gampong Peunayong gave a good enough response for a small number of Chinese living in Gampong Peunayong, because while trading in the Peunayong market, he had never had a problem with Chinese ethnicity. Except that sometimes Mr. Safrizal felt uncomfortable with the actions of the Chinese. The rest of the life of the Acehnese and Chinese traders went well, and got along well . In terms of keeping harmony, the way to do this is to invite each other and gather to chat at coffee shops. Of course, it is done during the spare time because most Chinese in Gampong Peunayong are busy in their respective shops . When conducting research, the author often sees Chinese and Acehnese people gathering in coffee shops. Some were just talking, and some were playing rock. The men more dominantly carry out conversations in this coffee shop. Meanwhile, women are rare. When asked whether it was permissible for Chinese to become village leaders, he replied that he strongly disagreed because, in his mind, if the ethnic Chinese became the leader, the people of Aceh would be neglected and neglected. It is because the Chinese only prioritize and care about their ethnicity. After all, this has never happened in Gampong Peunayong . The response of Mr. Joni, an employee at a car accessories shop belonging to Chinese Ethnicity: his response was quite good, and he was quite happy living with the Chinese Ethnicity. However, according to his characteristics, the Chinese ethnicity in Gampong Peunayong is divided into two specific groups. That is, some are soft, and some are hard. So, what made it uncomfortable was the Chinese, who were harsh . The specifics came from the Chinese ethnicity, not from their identity. This identity means that these specifications appear in the community by themselves, not brought from the ancestral characteristics of the Chinese ethnicity which came to Aceh. As we know, formerly, the Chinese came to Aceh of them for trading. Of course, traders must be gentle and polite to buyers . Regarding the attitude and kindness of the Chinese to the local community, they are quite friendly. Based on his experience working for 12 years as an employee of a car accessories shop owned by the Chinese, the treatment he has received so far has been good. Never once did he receive unpleasant treatment. When he is guilty, his employer only politely reprimands him . According to him, however, in this part of the world, ethnic minorities will not act harshly against the majority, except for each other. Because the Chinese realized he was an ethnic minority, he had to be kind and make the people of Aceh comfortable. For this reason, Joni feels safe and comfortable living with Chinese ethnicity . Even some of the Chinese follow Acehnese culture with a Muslim majority. For example, Chinese people perform circumcision on their sons. They also learn the Koran. Even in non-Muslim schools, there are Islamic Religious Education subjects to be taught to non-Muslim students. This involvement proves that the Chinese and the people of Aceh do not mind the religious differences that occur between the two . We should thank the Chinese ethnicity, because they are one of the drivers of economic growth in Gampong Peunayong. Moreover, Chinese ethnicity has lived for generations in Indonesia, especially Aceh, until they became an Indonesian citizen. We do not have to discriminate between the people of Aceh and Chinese ethnicity . Another response came from a fish trader at the Peunayong market, usually called Yahyek. According to him, buyers of Chinese ethnicity only bargain a little. Asking for less price is not too drastic. If they like it, they will buy it. If you do not like it, do not buy it. And so far, he is still comfortable and safe carrying out buying and selling interactions with ethnic Chinese . Jefriadi's response, as long as he lived in this environment, was never bothered by the presence of Chinese ethnicity. They in Peunayong live life as usual. Opinions on Journal of Islamic History and Manuscript Volume 02, Number 01, January-June 2023 religious differences, as long as they do not invite and do not follow their religion, everything is fine. For example, we are veiled, while they are not veiled. That is their right because they do not have to wear the veil in their religion. We also cannot force them to wear the veil . In keeping our respective religions, we must equally defend our faith and beliefs to avoid following other people's religions because to fall into another religion. Sometimes you do not have to be invited. If their faith is lacking, later, they will fall too. However, so far, the Chinese have never invited the people of Aceh to follow their religion. We should invite them to follow Islam. However, that has yet to happen so far because no one has started to invite. If some Chinese embrace Islam , it is purely from their desires . The response of Beni, a watch seller at the Peunayong market, to the Chinese ethnicity was also good. The Chinese and the people of Aceh mingle comfortably. To strengthen friendships, they often hold cooperation activities in the alley where they sell, such as cleaning clogged sewers, cleaning up trash, etcetera. All these activities are carried out for the common good . In terms of culture, Chinese ethnicity never held a Barongsai culture. Some Acehnese people helped organize the Barongsai culture because it was a big event. The presence of Chinese ethnicity in Aceh gives a new color to our knowledge of foreign cultures, such as Chinese culture. If they do not live in Aceh, we will never directly participate in other people's cultures. Participating, in this case, means helping, not participating in organizing their culture . --- The Negative Response of the Acehnese to the Chinese Ethnicity In addition to the positive response, the Acehnese people do not deny the negative feedbacks or responses that sometimes arise due to the relationship and interaction between the Chinese and the Acehnese. From the results of observations by the author, who saw directly the daily life of the Chinese and Acehnese, some got along well, were kind, cared for each other, and greeted each other. However, some do not pay attention to each other. In fact, during a week of direct observation, the writer had never encountered Chinese children playing with children from Acehnese. Chinese children only play with each other, as well as Acehnese children. This interaction raises its tendency for people who pay attention to these social conditions. Not only children's groups, even adult groups, especially mothers, do not gather and talk together. The place to establish relations between the Chinese and Acehnese is the market where they trade in buying and selling. However, they also mingle with each other when there are village activities, such as the activities of the PKK and posyandu women. Once again, this trend only occurs in a few Chinese and ethnic Acehnese. The Chinese ethnicity in Peunayong lives in one point or area. Moreover, the area with the most Chinese is Merpati Hamlet. In this hamlet, there are only one or two houses that Acehnese inhabits. The rest are houses belonging to Chinese ethnicity. When the writer entered the alleys in Merpati hamlet, there were characteristics of Chinese people's life. In front of every house, they have red lanterns hanging. This characteristic proves that although they live in Muslim-majority areas, they can still reflect their ethnic characteristics. In addition, the author's observations are inseparable from the interactions that occur in the market. Even though the market in Gampong Peunayong is a place for Acehnese ethnicity and Chinese ethnicity to build relationships, there is still a tendency between the two to emerge. One of them is that in the Peunayong market, Chinese ethnicity traders often trade in one alley. This trade means that in the alley, there are only Chinese traders. While in another alley, there are only traders from Acehnese. However, there is also a row of shophouses in this market inhabited by Chinese and Gampong officials are investigating further the extent of their role in these illegal churches. The elders in Gampong investigated every alley and even small alleys to find traces of this illegal church because the Chinese Ethnicity could have established an illegal church wherever they gathered. Initially, they only intended to gather together. Over time the place was used as a new place of worship for them . This interaction should not be done because the Gampong/government has provided an official church and monastery for ethnic Chinese to worship. According to Tgk Ridwan, if the minority religions increase their places of worship, then something that is not right will happen to the majority religion. Moreover, of course, religious minorities have bad intentions. Tgk Ridwan assumes that non-Muslims will spread their beliefs, which is fatal for the younger generation in Aceh regarding faith. Behind this, there are also many Chinese who have converted to Islam. Furthermore, the Gampong apparatus will make a special agenda for converts, such as lectures, meals, and so on . Another negative response emerged from a book and newspaper seller at the Peunayong market named Mr. Safrizal. His response to the Chinese ethnicity was that several Chinese people in Gampong Peunayong were unfriendly and unsociable. Not even to say hello. Even though he opened the conversation several times, the response from a small number of ethnic Chinese was not very good . Regarding his comfort in living with Chinese ethnicity, it is also similar. A small number of people of Chinese ethnicity do not respect the religious activities of the Acehnese people, for example, when the time for Friday prayers has arrived. These

The results show that Chinese ethnicity in Gampong Peunayong provided responses generated through interactions between Chinese and Acehnese. Responses and feedback from the public varied depending on their respective perspectives in the form of positive and negative responses.

Introduction Adolescence is a period of transition from childhood to adulthood, involving psychological changes and strong social influences, along with greater exposure to risk factors, making it a phase vulnerable to harmful behavior. 1 According to a systematic review, the prevalence of dental caries among adolescents aged 15 to 19 years, both in Brazil and the rest of the world, ranges from 59 to 90.4%. 2 These high rates underscore the importance of studies addressing factors associated with dental caries in this phase of life. Moreover, the most recent national oral health survey 3 reports that 13.6% of adolescents have never been to a dentist, a neglectfulness that may contribute to the poorer oral health status of this population. Dental visits are important to prevent dental caries and provide proper treatment, and have been associated with a lower prevalence of untreated dental caries in adolescents. 2 . Adolescents who do not receive socioeconomic support from their families have a greater prevalence of dental caries, probably due to the lack of dental visits and preventive measures. 4 This underscores the importance of evaluating the association between socioeconomic factors and oral health outcomes in this group. Previous studies have also suggested that a mother's schooling and the number of residents in the home are associated with dental caries. 5,6 An investigation into these factors is particularly important in developing countries, since the results may vary depending on regional differences. Associations have also been found between drug use and problems such as poor oral hygiene habits and dental caries, especially in adults, with little attention to adolescents. 7,8 Therefore, it is important to investigate the influence of drug use on dental caries in adolescents, since substance use is associated with lower adherence to dental treatment in this age group. 9 Moreover, drug abuse is commonly associated with dental caries, mainly due to neglected self-care and the detrimental effects of drugs on the soft and hard tissues of the oral cavity. 8 The influence of family cohesion on oral health in adolescents has been little explored in the literature. One study reports an association between poor oral health behavior, dental caries and low family cohesion, but the sample was limited to 15-year-olds at public schools. 10 Family cohesion constitutes the emotional ties that family members have with one another. This indicator reflects the level of dependence and independence among the components of a family, and should be studied at different times, since it changes as the adolescent develops. 11,12,13 Higher levels of family cohesion are believed to contribute to more adequate behavior on the part of adolescents, thereby reducing the likelihood of their developing impulsive and antisocial behavior 14 and having poor oral health habits. The central hypothesis of this study is that family cohesion is associated with dental caries among adolescents. Depending on the degree of family cohesion, family members exert a stronger or weaker influence on each other, ultimately affecting beliefs, behaviors and habits. 13 Thus, strengthening family cohesion is a valuable strategy for promoting the oral health of adolescents. 10,13,14,15 The aim of the present study was to investigate associations between dental caries and family cohesion, drug use, sociodemographic factors and visits to the dentist among adolescents aged 15 to 19 years. Investigating these associations can contribute to the establishment of preventive policies that are directed at oral issues and that incorporate factors associated with dental practice. --- Methodology Study design and sample size An a nalyt ical cross-sect ional st udy was conducted in Campina Grande, a medium-sized city in Brazil. This city has 407,472 residents, with 13,933 adolescents in the target age group 16 . The data collection period was between October 2016 and July 2017. The sample was composed of adolescents aged 15 to 19 years, enrolled in public and private schools in the city of Campina Grande. The sample size was calculated considering a 5% margin of error, 95% confidence interval and 50% prevalence of the condition, to obtain the largest possible sample. Two-stage probabilistic cluster sampling was performed. First, the schools were chosen randomly, and then the students were selected using a simple random sampling method at each school. The sample was proportional to the six administrative districts in the city, to reproduce the characteristics of the population. The minimum sample was determined as 384 adolescents, and was corrected for the study design by applying a factor of 1.6, resulting in 615 adolescents. Finally, 20% was added to compensate for possible dropouts, yielding a final sample of 769 adolescents. --- Eligibility criteria This study included literate adolescents between 15 and 19 years old, enrolled in public and private schools in the city of Campina Grande. The exclusion criteria were adolescents with cognitive impairment that affected learning and reading , those wearing orthodontic appliances at the time of the study, and those who still had primary teeth. --- Training and calibration exercises The Nyvad criteria were used to diagnose the dental caries 17 . Training was conducted in two steps . In the theoretical step, an expert in the field performed an in-depth analysis of the diagnostic criteria with two dentists. In the practical step, 50 children were examined and reexamined following a seven-day interval to determine the interexaminer and intraexaminer agreement. --- Pilot study A pilot study was conducted with 50 adolescents . These participants were selected by convenience, and were not included in the main study. The results of the pilot study indicated that there was no need to alter the proposed methods. --- Collection of non-clinical data The questionnaires were self-administered by the adolescents and their parents/guardians. Meetings were held with the parents/guardians prior to the data collection to clarify the procedures and importance of the study. At this time, the parents answered a questionnaire addressing sociodemographic characteristics . In addition, the adolescents were asked whether they had ever been to a dentist. The Family Adaptability and Cohesion Evaluation Scales were used to investigate family cohesion, 18,19 and were answered by the adolescents. FACES III has 10 questions on family cohesion and 10 on family adaptability. The questions are related to daily activities and level of emotional dependence among family members. The sum of the family cohesion questions indicates the adolescent's degree of family cohesion. This instrument establishes fours levels of family cohesion: disengaged -lack of an affective union among family members; separated -moderate affective union among family members; connected -considerable affective union among family members; and enmeshed -maximum affective union among family members. 19 The Alcohol, Smoking and Substance Involvement Screening Test developed by the World Health Organization 20 was employed to evaluate the use of psychoactive substances. The students answered the ASSIST questionnaire in a separate room with no external influences to ensure privacy. The questionnaire addresses licit and illicit drug use, use frequency and risk of psychological disturbance due to drug abuse. It is a self-administered questionnaire with eight items. The item addressing drug use frequency in the previous three months was included in the present study. --- Collection of clinical data The adolescents brushed their teeth under supervision and received topical fluoride prior to the clinical examinations. They were examined individually in a reserved room, sitting in a school chair in front of the examiner, who was equipped with a head lamp , sterilized mouth mirror , sterilized Williams probe and individual protective equipment. The Nyvad criteria 17 were used to classify the dental caries, based on the severity of the lesions. These criteria have been validated for use in clinical practice and research in the field of dentistry. The following classification is used, in ascending order: a) active carious lesion on an intact surface; b) active carious lesion on a discontinuous surface; c) active carious lesion with cavitation; d) inactive carious lesion on an intact surface; e) inactive carious lesion on a discontinuous surface; f) inactive carious lesion with cavitation; g) restoration in good state; h) restoration with active carious lesion. After the examinations, the adolescents received verbal recommendations regarding oral hygiene, and were instructed to seek dental care at a public service center in their neighborhood, when needed. --- Directed acyclic graph A directed acyclic graph was created to select covariables for the statistical adjustment, and support the causal interpretation of the effect of exposure on the outcome. DAG is an important tool for reducing bias in epidemiologic studies, since it enables estimating the effect of different independent variables on the outcome, and suggests a minimally sufficient adjustment. Moreover, DAG presents causal directions and facilitates the visualization of the relationships among variables. 21 Both investigated and uninvestigated variables were incorporated into the model. This step led to the identification of confounding variables that could be controlled in the final model . --- Statistical analysis Organization of the data and statistical analysis were performed using STATA version 15 . The number of cavitated lesions was the dependent variable, and was treated as a discrete numeric variable. Codes 3 and 6 of the Nyvad criteria were used in the present study, since these codes represent the worst possible outcome for dental caries, thereby exerting a greater impact on adolescents. The independent variables were the sociodemographic characteristics, family cohesion, drug use and visits to the dentist. Social class was classified into two categories , based on the Brazilian Economic Classification Criteria. These criteria depend on the number of household appliances, and the householder's education and access to public utility services. They allow a social class to be classified according to five strata , based on the estimated average household income 22 . The cutoff for the guardian's age was the median . Elementary school is commonly considered a cutoff point for mother's schooling in Brazil, since it discriminates between low to medium and high levels of education. 23 Drug use, family cohesion and dental visits were categorized according to the recommendations of the validated questionnaires. 3,19,20 The association between these variables and the outcome were tested using robust Poisson regression analysis for complex samples. Variables with a p-value < 0.20 in the bivariate model were incorporated into the multivariate model, and those with a p-value < 0.05 in the final model were considered as significantly associated with the outcome. --- Ethical clearance --- Results The final sample was composed of 746 adolescents . A total of 497 adolescents attended public schools and 249 attended private schools. Dropouts were counted as three consecutive failures of adolescents to appear on the days scheduled for the examinations. Table 1 shows the characterization of the sample. Most adolescents self-declared themselves as having non-white skin color ; 42.1% were the eldest child; the female sex accounted for 59.5% of the sample; the majority lived with up to five people in the home , had been to a dentist at least once in their lifetime and had mothers who had more than eight years of schooling . Most adolescents reported needing dental treatment and 41.6% had cavitated lesions. A large portion of the adolescents reported disengaged family cohesion . In the multivariate analysis , the variables that remained in the final model were disengaged , separated and connected levels of family cohesion; and high social class . --- Discussion In the present study, the prevalence of dental caries in adolescents was high, and the number of cavitated lesions was associated with family cohesion and social class. This is the first study to associate family cohesion and dental caries in a school-based representative sample of adolescents aged 15 to 19 years. The high prevalence of dental caries may be related to the diagnostic criteria, which also consider carious lesions in the initial stage . 17 This aspect has been observed in previous studies using the same index. 24,25,26 The Nyvad index is proposed for use in clinical practice and research in dentistry, and can differentiate the various stages of caries, thus making it useful for epidemiological studies. In the present investigation, a higher social class was associated with fewer cavitated lesions. Previous studies report similar findings. 4,24,27 An individual's cognizance of belonging to a higher social class could exert a positive influence on his access to oral health information and dental services, thereby reducing the dental caries experience. 28 Moreover, a higher social class may contribute to social cohesion. It has been claimed that social cohesion enhances self-confidence and reduces psychosocial stress, thus leading to better general and oral health behaviors. 29,30 Drug use was not associated with the number of cavitated lesions among the adolescents, unlike the results reported in previous studies. 31,32 This likely occurred because drug use may have been considered at some time in life, but may not represent frequency of use. It is important to conduct longitudinal studies considering the frequency of drug use. Another possible explanation for the non-association between drug use and cavitated lesions is the underestimation of drug use. Adolescents may be reluctant to report the truth. 33 However, for the purposes of the present study, the adolescents answered the ASSIST questionnaire in a separate room with no external influences to ensure privacy. Regarding family cohesion, the results show that adolescents with low to moderate levels of family union had more cavitated lesions. A previous study found an association between family cohesion and a cariogenic diet in female adolescents 15 . Another study found an association between low levels of family cohesion and dental caries in 15-year-old adolescents enrolled in public schools. 10 The present investigation included private schools together with public schools, and older adolescents, thus showing that the influence of family cohesion on the number of dental caries continues to be important not only in early but also in late adolescence, and regardless of the type of school. Noteworthily, the present study enabled better representation, compared with the previously cited study. It is likely that the association between dental caries and family cohesion is mediated by the influence of preventive habits related to dental caries. 10,34 Thus, a higher degree of family cohesion exerts a positive influence on the prevention of dental caries. The present findings underscore the importance of oral health promotion actions in the school setting, 35 which take into account socioeconomic and familial factors regarding the prevention of dental caries in adolescents. The major limitation of the present study was its cross-sectional design, which did not enable a cause-and-effect relationships to be established among the variables analyzed. The strengths of this study were its representative school-based sample, use of validated instruments and calibration of the examiners. Moreover, this study followed the recommendations of the Strengthening the Reporting of Observational Studies in Epidemiology initiative, 36 and demonstrated the importance of evaluating the influence of family relations on dental caries. --- Conclusions In conclusion, this paper posited that adolescents with a lower socioeconomic status and those whose family cohesion is classified as disengaged, separated or connected had a larger number of cavitated lesions.

The aim of this study was to evaluate the association between number of cavitated dental caries in adolescents and family cohesion, drug use, sociodemographic factors and visits to the dentist. A cross-sectional study was conducted with 746 adolescents aged 15 to 19 years from Campina Grande, Brazil. The parents answered a questionnaire addressing sociodemographic data, and the adolescents answered questionnaires on drug use, type of family cohesion and visits to the dentist. Two examiners underwent training and calibration exercises (K > 0.80) to diagnose dental caries using the Nyvad criteria. A directed acyclic graph was created to select the variables to be controlled in the statistical model. Associations between the independent variables and the outcome were determined using robust Poisson Regression analysis for complex samples (α = 5%). Rate ratios (RR) and 95% confidence intervals (CI) were calculated. The prevalence of dental caries and cavitated lesions among the adolescents was 92.8% and 41.6%, respectively. The following variables remained associated with the number of cavitated lesions in the multivariate analysis:

INTRODUCTION The emergence of e-health communication and e-health promotion through new media platforms has the potential to significantly contribute to the promotion of public health at individual, community and societal levels. While accumulated evidence supports the effectiveness of mass media for health promotion , studies have noted the disappointing impact of mass media on health . This has been attributed, in part, to a lack of methodological understanding of the media process . This criticism can be levelled particularly at new media platforms which, unlike traditional media, lack a substantive research foundation with limited, albeit growing, practical application for health promotion . Although there are similarities between traditional media and new media, which facilitates knowledge transfer between the two, there are differences. A unique feature of new media is the ability of individuals to instigate and participate in mass communication , with messages having the potential to be disseminated to very large audiences. Traditionally, individuals have not always had such easy access to this level of potential influence. This is due to the selection and filtering processes of traditional media generally constraining message dissemination by restricting access to those individuals or organizations that reinforce the media's own agenda. These constraints and restraints are not a feature of new media. The impact of this to the communication process for new media is most evident in terms of the nature of influence . Boyd et al. claim that through new media, people exchange on individual, not topical, threads and thus individuals have more space and opportunities to have an influential impact. As a result individuals, recognizing the potential of new media, have actively used it to promote their point of view and disseminate it to wideranging audiences. Those that have been consistently successful have been labelled 'influentials'. The concept of influentials draws from seminal work by Lazarsfeld et al. , who developed the notion of 'opinion leaders' which was positioned within a process of diffusion to propose that ideas flow from mass media to opinion leaders and then to the rest of the community. This is the fore runner of the Theory of the Diffusion of Innovations, which attributes power to opinion leaders in influencing others and their decisions positively or negatively . Weimann coined the term 'influentials', which has come to be used, along with 'influencers', in new media communication studies . Influentials have been defined as 'individuals who disproportionately impact the spread of information or some related behaviour of interest' [ , p. 2]. Some of the characteristics of those that disproportionally influence others have been identified. It has been found that they usually seek information and have wideranging and strong connections with many people , generating a high level of public recognition . In addition, they have high exposure to mass media, contribute socially through participating in community activities , are credible , competent and socially accessible, and they conform to system norms . Influentials can be celebrities, social activists, politicians, religious leaders or sports heroes . There is empirical evidence for the use of influentials to effect change which is confirmed, not only in the political, social, economic sectors and religious affairs, but also in public health and health promotion . Using new media's ability to influence can enhance diffusion and so support public health evidence-based practices . One way influentials are thought to do this is by acting as change agents within targeted communities . In practice, many health promotion programmes report using influentials for multiple public health issues, such as breast screening , prevention of sexually transmitted diseases, including HIV/AIDS , tobacco use prevention and others . While these studies have used the concept of influentials to promote public health, a lack of wellstudied models and theoretical frameworks to guide the identification of influentials in populations has been identified . The failure to determine the real influentials can significantly limit the success of such a strategy . A new media platform that has seen exponential growth in use and which individuals can access directly is Twitter. Twitter is a social, micro-blogging service comprising, according to its official website, 'an information network' that allows users to send and read media messages of a maximum of 140 characters. It is the fourth-most used new media platform globally, according to PewInternet. Org , with over 974 million registered accounts . This is reflected in Saudi Arabia where 77% of Internet users have a Twitter account, and 41% of these, that is over 5 million people, are active users. . The popularity of Twitter among Saudis means that it has great potential as a communications platform, which suggests the promising impact of the use of influentials in health promotion interventions. In response to the potential impact of influentials, various techniques using the powerful measuring tools and data gathering abilities of new media platforms such as Twitter have been used in attempts to identify and evaluate the influence of users . The theoretical bases of influence confirm the extrusion correlation between popularity and the ability to influence others . Connection power and interaction ability are the two main types of new media measurement . Twitter influence and influentials have been studied previously . On Twitter, the number of 'followers', which is the term for the number of users who follow the account , is a well-known popularity indicator . Thus, the number of followers can be used to measure influence ability and it is already widely used to evaluate Twitter user influence . This is supported by Bakshy et al. who examined the identification of Twitter influentials and concluded the number of followers is an informative feature of a Twitter user's influence . In addition to the number of followers, their study revealed that past influence is also an indicator and future predictor for Twitter influence . Yet, there is open controversy about the correlation between popularity and influence. Some researchers differentiate between popularity and influence, and they have found popularity directly correlates with the number of followers, while influence is more strongly related to level of engagement. Many other indicators of influence have been tested. These indicators can be used to support the accuracy of measuring influence among Twitter users and include, but are not limited to, the following: retweets, replies and mentions . 'Retweets' on Twitter involve the reposting of original tweets, 'replies' are comments on an original or reposted tweet and 'mentions' involve the specific citing of a user name within a tweet . 'PageRank' is the ranking score Google calculates based on factors such as the number of links leading to that page . Additionally, proportion and ratio calculations of the above variables can provide extra scoring measures and rankings. Based on such calculations, various tools and services available for Twitter and other new media platforms can provide measures of these indicators. Notably, it is confirmed that due to the complexity of new media, these indicators can be affected by other variables, such as time, location, topic and culture . Based on reviewing these parameters and indicators, it seems fair to propose that while the number of followers can be used as a direct indicator of connection ability, other measures can provide indicator measures that evaluate the level of interaction and engagement of users with the potential influentials. In sum, benefiting from the balance of power being tilted towards the role of the individual, the influentials on new media have more power to directly influence others compared with their counterparts using traditional media. The role of influentials in influencing people can be used for the promotion of the public's health. While multiple techniques and measures of influence have been identified, there is ambiguity about those most appropriate to identify influentials on new media platforms such as Twitter. This study aims to contribute to the evidence base for best practices in new media health promotion through the application and comparison of multiple indicators of influence in the domain of public health in Saudi Arabia through the new media platform Twitter. Research objectives include: - --- METHODS This study targets Saudi Arabia Twitter accounts to identify the 100 accounts with the most potential to influence. Thus, for these accounts, the study considers accounts of Saudi origin and accounts that target Saudis. Moreover, it considers the abilities of these accounts to influence according to their present rankings, not in relation to any specific topic or domain. To achieve this, this study used the number of followers as the main measure of influence, while four different scoring tools are applied to support the accuracy of this measure. The process is described through the stages of primary list development, filtering, classification and finally analysis. --- Primary list Manually, it is difficult to sort Twitter accounts according to the number of followers. Therefore, initial lists were compiled using Tweepar and SocialBakers . Both websites provide lists of the top accounts by country based on the number of followers. Two sources were used to avoid any accounts being missed by either source. Moreover, given that we expected exclusions through the filtering process, extra users were targeted to be included in this initial list. Two lists of 150 ranked users were generated by these two sources and by deleting the duplicates, a list of 185 users resulted. All accounts were checked on the Twitter official site to validate the number of followers and to remove any deleted accounts. Three accounts were not available on Twitter and were excluded from the list. The final list of top Saudi influential users based on the number of followers contained 182 users. --- Filtering stage The study applied scoring tools to consider additional indicators in its evaluation of users' influence. Fake users and fraudulent accounts are a feature of Twitter, confirmed and researched by different studies with the contribution of Twitter itself . Therefore, a filtering process was applied for the primary list that included four different influence-scoring tools. This was to enhance the accuracy of measurements by excluding any user that showed low influence ability on Twitter compared with others. These scoring tools use different algorithms and calculation methods to measure influence, meaning that there is a greater chance of overlapping parameters than if only one tool was used. For each user, four Twitter influence scores were collated: Social Authority by MOZ , PeerIndex , Kred and Klout . Social Authority, , is based on the retweet rate of users' last few hundred tweets, the recency of those tweets and applied a retweetbased model based on user profile data. PeerIndex uses an algorithm that considers 'the speed and quantity by which users spot, share content on any specific topic'. Kred measures the influence using mixed parameters, including retweets, replies, mentions and number of followers . Klout uses various signals from different networks to compute the influence score . The score is not limited to Twitter, as adding a different dimension can strengthen the evaluation of influence. Although some of these tools claim they use clear and transparent parameters and calculations, the internal calculations of these parameters were all hidden. The calculation of the mean for each tool was computed, and then negative standard deviations were applied to strengthen the inclusion point of the filtered list. For some tools, there was missing data, as scores for a few users were not recorded; these users were filtered out of the list and were not included in the calculation of means. All measures and scores were defined for all users at the same time on 11 August 2014. The filtering process then continued by eliminating any users below the minimal cut-off points . This means any user with a score below was filtered out. The penultimate final list comprised 111 users who represent the top Saudi influentials according to the study filtering procedure. --- Classification stage In the classification stage, the first step was to classify accounts into either individual or organizational accounts. Then individual accounts were classified into male or female accounts. For the group classification, reviewing the list generated 10 categories according to user popularity. All users can be classified into at least one of the categories below, including users who are unpopular or unknown. If any accounts are known as media celebrities in addition to another domain, they were classified under the other domain group. That is because the media are a communication interface that is difficult to isolate from any other channel of popularity. For the purpose of analysis, simple coding of all these categories was performed. Because most accounts were well-known accounts, classifying them into categories was straightforward for one researcher who was familiar with the Saudi environment. However, to validate the classification, an external observer was invited to classify the accounts on the list. The inter-rater reliability measure was then calculated by computing Kappa statistics . The benchmark scale for the strength of agreement proposed by Fleiss et al. was considered to evaluate the agreement of the study classification with the external observer . The kappa statistic was 0.927, which indicates excellent agreement with the external observer on account classification . Finally, unknown accounts were excluded from the list, resulting in a total of 99 accounts on the final list of top Saudi Twitter users. Simple ratio and percentage calculations were then computed to analyse the data and represent the most influential group among Saudi Twitter users. Table 2 summarizes the stages of the procedure used in the study methods. --- RESULTS In the identified top 99 Saudi Twitter influential users, there were 72 individual accounts and 27 organizational accounts . After differentiating individual and organizational accounts, two lists of top influentials were identified, as shown in Table 3. Among the individual accounts, men were the larger group with 94% compared with 5% for women. Considering the results of the group classification, religious men/women were the largest group, with 25 from 99 accounts, with the most potential to influence, followed by traditional media accounts , sport , new media , politics and companies , health and accounts of members of the Saudi Royal Family . --- DISCUSSION As shown by the data, the main players on new media platforms within the Saudi community are religious men, politicians, members of the Saudi royal family and celebrities from sports, entertainment, media and the new media. In addition to these individual-level influentials, many organizational accounts of influence have an impact on Saudis through the new media platforms. The data provide a well-defined Saudi Twitter profile of influentials, indicating most influentials on the list are prototypical influentials when evaluated according to the characteristics of influentials expounded in various studies . For instance, the identified account holders are well known by Saudis on Twitter and their high numbers of followers give them the potential ability to connect with people widely. This suggests a positive evaluation of the efficacy of the measurement indicators and tools used in this study to assess and identify Twitter users' influence. The presence of women, among individual users, was notably very weak in the Saudi Twitter influence profile, with only four accounts held by women among the total 74 individual influentials' accounts. This is true, despite Twitter's global statistics showing 53% of Twitter users are female . Moreover, based on the gender specification in the profile, an analysis of a random sample of 100 000 followers of the Saudi Ministry of Health's Twitter account showed that 41% of followers are female . Consistent with the sensitive presence of women within Saudi society, these results suggest that while women have a strong presence among Saudi Twitter users, they have a weak presence among Saudi Twitter influentials. This is particularly notable in the health domain, which is an area of interest to women and men, though there are no woman influentials on the list. The study data strongly validate results from previous research that identifies the Saudi population as highly influenced by religion, specifically Islam, in all domains of life , including health decisions . Many Islamic values are consistent with public health values, and religion and religious women/men can potentially contribute to the promotion of the public's health in Saudi Arabia. Also confirmed by the study data, media influentials are other important influencing agents among Saudis. Television celebrities have been used in promotional activities previously with clear benefits . However, it is important to consider the media as an interface for communication processes, including the function of influencing, which will result in an overlapping classification of these influentials, specifically when traditional media channels are separated from new media platforms. Besides the importance of the identification of influentials, classifying them is also crucial to using their power of influence. The results showed a variety of groups with diverse levels of influence among Saudi Twitter influentials. It is significant for health promotion that the data identify four of the top influentials' accounts in the health domain. Three were individual accounts, and only one was for an organization, which is the Saudi Ministry of Health. This suggests that new media, and in particular Twitter, is a promising target for public health interventions at both the organizational and individual levels. Nevertheless, it also indicates a distinct lack of influence at the organizational level. The main influential domains identified among Saudi Twitter users were religion, sport, media and policy. This suggests that these four domains are areas of interest for Saudis and have the potential to be used for public health interventions by identifying influentials in these areas and using them together with influential health accounts to promote health. This use of multiple influential accounts addressing the same domain, both individual and organizational, would appear to be the most effective approach. However, Bakshy et al. propose a selection strategy which targets different groups of influentials at once instead of segmenting them in this way . This grouping requires further research. While many users identified were known in Saudi Arabia before new media emerged, many users became known only through new media platforms. This supports the assertion that new media platforms provide individuals greater opportunity in which to directly influence others unimpaired by the constraints of the traditional media. The strong presence of new media among the Saudi Arabian population confirms individuals have the capacity to be potential influentials in a way that was not possible previously with restricted access to traditional media exposure. Therefore, it seems fair to suggest individuals are the key to success of public health and health promotion interventions using new media platforms. Nevertheless, the traditional influentials that were popular before the development of the new media platforms benefited from new media by increasing their popularity and influence. Thus, new media cannot be considered an extension of traditional media, as it is a new interface for communication and interaction between people. Many influentials in Saudi appear to be using the new media platforms as well as and not as a replacement for traditional media. Moreover, this emphasizes the importance of understanding the theoretical basis of the impact of influentials and opinion leaders on new media platforms. Particularly, for health promotion, understanding the theoretical frameworks relevant to using influentials in health domains will improve the outcomes of such practices. --- CONCLUSION Using influentials has the potential to be an effective strategy for promoting health at the level of the individual, the community and society. At an individual level lifestyle interventions and communicable disease awareness programmes are examples, with activities, such as re-framing road traffic accidents as a public health issue an example at a societal level. Identifying influentials that can champion health is an important first step in the process of harnessing the power of their influence. This study provides a well-defined profile of influential Twitter users in Saudi Arabia, which can be effectively used in the promotion of public health. However, further research is needed to test the theory that influencers on Twitter can be used to proactively and positively influence health. The methods used to identify influentials in this study can be applied to other countries for the same purpose.

New media platforms, such as Twitter, provide the ideal opportunity to positively influence the health of large audiences. Saudi Arabia has one of the highest number of Twitter users of any country, some of whom are very influential in setting agendas and contributing to the dissemination of ideas. Those opinion leaders, both individuals and organizations, influential in the new media environment have the potential to raise awareness of health issues, advocate for health and potentially instigate change at a social level. To realize the potential of the new media platforms for public health, the function of opinion leaders is key. This study aims to identify and profile the most influential Twitter accounts in Saudi Arabia. Multiple measures, including: number of followers and four influence scores, were used to evaluate Twitter accounts. The data were then filtered and analysed using ratio and percentage calculations to identify the most influential users. In total, 99 Saudi Twitter accounts were classified, resulting in the identification of 25 religious men/women, 16 traditional media, 14 sports related, 10 new media, 6 political, 6 company and 4 health accounts. The methods used to identify the key influential Saudi accounts can be applied to inform profile development of Twitter users in other countries.

Introduction Social interactions affect a variety of behaviors and economic outcomes, including the formation of opinions and tastes, investment in human capital, access to jobs and credit, social mobility, subjective well-being and the emergence of collective action, to name a few. While face-to-face interactions have reportedly been declining in many countries over the last two decades , participation in social networking sites , such as Facebook and Twitter, has steeply risen . 3 The advent of online social networks has radically changed the way we interact with others and this change can have major economic and welfare consequences. In Bowling Alone, Putnam suggested that technology-based private entertainment, such as television, could replace face-to-face meetings and civic engagement in individual preferences. This claim was supported in virtually any empirical test on the role of television, which was found to displace encounters with friends, associational activities and political participation . Following Putnam's argument about television, early Internet studies advanced the "crowding-out hypothesis", according to which Internet use crowds-out social engagement. As television, a unidirectional mass medium, displaced so many activities, it seems reasonable to argue that the Internet, which allows for interactive communication, might induce an even more powerful substitution effect . The first empirical studies on the relationship between Internet use and face-to-face interactions supported the crowding-out hypothesis . Subsequent studies, on the other hand, found conflicting results, suggesting that the effect of Internet use may vary with users' preferences and personal characteristics . Yet, these studies are not conclusive; at that time, in fact, using the Internet was predominantly a solitary activity that was connected with private entertainment. The advent of online social networks radically transformed the way that people use the Internet, which largely extended the possibilities to interact with others. Despite the extent of the transformations brought about by online networking, existing research on the relationship between face-to-face interaction and SNS-mediated interaction is limited. There are empirical studies on the effect of broadband access on outcomes such as social participation and voting behavior . A few authors specifically addressed the role of SNS in some aspects of social capital, such as face-to-face interaction and trust . These works put the crowding-out hypothesis into perspective, suggesting that face-to-face and Internet-mediated interaction may rather be complementary. Additionally, while early sociological studies implicitly suggested that there is a risk of segregation of the two populations of Internet users and socially active individuals, more recent works illustrate the emergence of two main types of social actors: those who only interact with others face-to-face and those who develop their social life both online and through face-to-face interactions . In addition, a third population of socially isolated individuals who devote an increasing share of their time to work and private consumption seems to be growing in richer and emerging countries . Antoci et al. showed how the choice of social isolation might be a rational response, allowing individuals to adapt to the relational poverty of the surrounding environment and to the reduction in leisure time. To date, however, we lack a theoretical framework to study how social interaction via SNS relates to interaction via physical encounters and to the intentional withdrawal from social participation that was feared by Putnam in Bowling Alone. We add to the previous literature by developing an evolutionary game model of SNS-mediated interaction. In our simplified framework, agents can choose among three possible strategies of social interaction. Individuals who want to be socially active can adopt two alternative strategies: 1) to interact by means of both SNS and face-to-face encounters or 2) not to use SNS and only develop social relationships by means of face-to-face encounters. The distinctive trait of these two strategies is the use of SNS. 4 Alternatively, agents can opt out from both types of interaction and renounce social participation. This strategy of social isolation may be viewed as a drastic form of adaptation to the conditions of social decay, increasing busyness and declining opportunities for social engagement, a strategy that provides constant payoffs that are independent of the behaviors of others. The analysis shows that, depending on the configuration of payoffs and the initial distribution of the three strategies in the population, different Nash equilibria can be reached. In particular, we found that the stationary state in which all individuals choose isolation is always locally attractive. Thus, it represents a social poverty trap, i.e., an equilibrium, in which no one has an interest in interacting with others and everybody devotes all of their available time to work or to private consumption. Only the stationary states in which all individuals play the same strategy can be attractive Nash equilibria. The dynamics leading to such states are self-feeding, to the extent to which agents get a higher payoff when they interact with agents adopting their same strategy. When the three stationary states are simultaneously attractive, the social poverty trap is always Pareto dominated by the other equilibria and, therefore, it can be considered as the worst-case scenario. Depending on the parameters, the stationary state in which all individuals socially participate through SNS may be the second-best scenario, which is Pareto dominated by the equilibrium in which everyone interacts exclusively by means of physical encounters. Social interaction via SNS, in fact, may be interpreted as a coping response that allows individuals to "defend" their social life from increasing busyness and the reduction in leisure time. In this case, the widening of the agents' opportunity set for social interactions can prevent the achievement of the first best scenario. At the same time, however, it allows society to avoid the worst-case scenario of the attractive social poverty trap. In all cases, the achievement of a specific equilibrium depends on the initial distribution of the three ways of social interaction in the population. The propensity for discrimination of socially active individuals defines the structure of the basin of attraction of the social poverty trap. 5 The higher the propensity for discrimination, in fact, the greater the probability that both kinds of agents will end up segregating themselves from the rest of the population, making society fall into the trap. Our contribution is related to three strands of the literature. The first includes empirical studies that documented a decline in face-to-face social participation in many countries . We add to this literature by providing a theoretical framework that helps us to understand the roots of the decline in participation. The second strand is that of economists who theoretically and empirically analyzed how the Internet use may affect social capital . Antoci et al. modelled the choice between two means of social participation, based on Internet-mediated and face-to-face interaction, in a framework where the time available for social participation is exogenously given. Antoci et al. added to previous work by including the choice to withdraw entirely from social participation. The evolutionary framework that is presented in this paper contributes to this body of research in several ways. First, we introduce a new specification of the social interaction mechanism that determines the probability of meeting between individuals belonging to each of the three sub-populations considered. Second, the resulting configuration of payoffs -which allows the outcomes of interaction to vary according to the type of agent with which people are matched-takes into account the propensity for discrimination, allowing us to study its dynamic outcomes in terms of segregation. This latter aspect links our work to a third literature that refers to theoretical studies on social interaction and segregation. Schelling's seminal contribution explained how people's preferences for interaction with similar others-and, therefore, for discrimination against different others-generates dynamics that naturally lead to segregation. Bischi and Merlone developed Shelling's work by formalizing a two-dimensional dynamic system to study segregation. The authors showed how adaptive rules shape evolutive paths that lead to the emergence of different collective behaviors in the long run. When members of a population are characterized by a limited tolerance of diversity, the complete separation of different populations may occur. Radi et al. further developed this framework by analyzing the role of regulating institutions constraining the number of individuals of a population that are allowed to enter and exit the system. Our work adds to this literature by illustrating how the configuration of payoffs drives population dynamics towards segregation. If we allow for a configuration of payoffs that reflects a preference for interaction with similar others, then dynamics will lead to the complete separation of the three populations accounted for in our framework. This is consistent with Bischi and Merlone . The rest of the paper is organized as follows. In section two, we describe the model and analyze the evolutionary dynamics. Sections four and five present the basic results and the classification of dynamic regimes. Section six discusses the possible dynamics predicted by the model for a specific distribution of the different forms of participation suggested by the existing empirical literature. Section seven concludes. --- The Model --- The Social Interaction Mechanism We consider an economy made up of identical individuals. In each instant of time t, each individual has to choose one of the pure strategies of social interaction mentioned in the introduction of this paper: 1) Interaction via online social networks and face-to-face. We call this strategy SN . The SN strategy entails different degrees of SNSmediated interaction according to individual preferences. In general, we think of SN agents as individuals who develop social ties via SNS at their convenience-for example, by using Facebook to stay in touch with friends and acquaintances or to establish contacts with unknown others-and meet their contacts in person whenever they want to or have time. 2) Interaction by exclusive means of face-to-face encounters. We call this strategy NS . The empirical evidence shows that, despite the steep rise in the use of SNS, a remarkable number of online adults choose not to use them. The distinctive trait of the two strategies is the use of SNS for social interaction, which has two features: it allows asynchronous and complex interactions and it generates club effects that may favor segregation to the extent to which users receive different payoffs when dealing with other users or with non-users. 3) Social isolation. This is a strategy in which agents prefer to devote all of their time to work and to forms of private consumption that do not entail any significant relationships, either online or face-to-face . We call this strategy NP . NP players tend to replace relational goods with material goods . We assume that NP agents do not retire from work and that their social relations are limited to on-the-job interactions. The withdrawal from social interactions modelled with the NP strategy may be viewed as a drastic form of adaptation to the conditions of social decay that make NP players' payoffs constant and completely independent of the behavior of others. The notion of defensive choices is not new in the literature. Hirsch was the first to introduce the concept of defensive consumption induced by the negative externalities of growth. This kind of consumption may occur in response to a change in the physical or social environment: "If the environment deteriorates, for example, through dirtier air or more crowded roads, then a shift in resources to counter these 'bads' does not represent a change in consumer tastes but a response, on the basis of existing tastes, to a reduction in net welfare" . Antoci et al. generalized the study of defensive consumption choices to the case of a deteriorating social environment. If the social environment deteriorates, for example, in relation to a shift in prevailing social values or to a decline in the opportunities for social engagement, then individuals might want to replace the production and consumption of relational goods with the production and consumption of private goods. 6 The authors suggested that the reduction in the time available for social participation could trigger self-feeding processes, leading to the progressive erosion of the stock of social capital. We assume that the sizes of the three sub-populations of individuals playing strategies SN, NS and NP at time t are expressed by the real variables 𝑥 1 , 𝑥 2 , 𝑥 3 , respectively. The size of the total population is normalized to 1, so that 𝑥 1 , 𝑥 2 , 𝑥 3 ≥ 0 and 𝑥 1 + 𝑥 2 + 𝑥 3 = 1 hold. We establish that individuals enjoying their leisure time-which coincides, by assumption, with their social participation time-are in L mode. By contrast, those who are currently working or engaged in private activities that have no effect on the payoffs of others are in W mode. All individuals choosing the NP strategy are always in W mode. The social interaction mechanism, which determines the payoffs of each strategy, is described by the following assumptions. In each instant of time t: Therefore, in each instant of time t: 1) A share l ∈ of the sub-populations 𝑥 1 and 𝑥 2 is in L mode. The remaining share, 1-l, is in W mode. 2) A share n ∈ of the sub-population of size 𝑙𝑥 1 interacts online via a SNS with individuals of the same type, while a share 1-n of such a sub-population interacts via face-to-face encounters both with individuals of the same type and with individuals belonging to the sub-population of size 𝑙𝑥 2 . 3) On the other hand, L mode individuals playing the NS strategy interact with L mode individuals playing the same strategy and with the share 1-n of L mode individuals playing the SN strategy and currently interacting via face-to-face encounters. --- Payoffs According to this game framework: We assume that every W mode individual obtains the payoff α, where α is a strictly positive parameter, independently of the strategy he adopts, and from the distribution 𝑥 1 , 𝑥 2 , 𝑥 3 of the strategies in the population. Furthermore, we assume that every L mode individual obtains a payoff equal to 0 when interacting with a W mode individual, while he obtains the payoffs expressed in the following table when interacting with another L mode individual: The parameter 𝛽 measures the payoff of an L mode individual adopting the SN strategy when The expected payoffs of strategies SN and NS are given respectively by: 𝐸𝑃 𝑆𝑁 = 𝛼 + 𝑙𝑛 + 𝑙[𝛾𝑙𝑥 1 + 𝛿𝑙𝑥 2 ] = = 𝛼 + 𝛽𝑙 2 𝑛 2 𝑥 1 + 𝛾𝑙 2 2 𝑥 1 + 𝛿𝑙 2 𝑥 2 𝐸𝑃 𝑁𝑆 = 𝛼 + 𝑙[𝜀𝑙𝑥 1 + 𝜂𝑙𝑥 2 ] = = 𝛼 + 𝜀𝑙 2 𝑥 1 + 𝜂𝑙 2 𝑥 2 while the expected payoff of an individual adopting the NP strategy is given by: The payoffs highlight some points about discrimination. First, a clear separation occurs between those who choose to withdraw from social interaction and all the other players. In a sense, NP players choose to segregate themselves from the rest of the population. Second, when SN players spend their leisure time interacting via SNS, they de facto segregate themselves from the two populations of NS and NP players, who do not use online social networks. 𝐸𝑃 𝑁𝑃 = 𝛼 > 0 The sub-populations of individuals playing the SN and NS strategies can only meet in the context of face-to-face interactions. The two extreme cases 0 and  0 entail discrimination. In these cases, in fact, when individuals adopting different strategies of participation meet face-to-face, they get a null or a negative reward. As a result, they will prefer to interact with individuals of their same type. For example, SN players may want to check what happens in their online networks while having dinner with friends. NS players, who are not familiar with SNS, may, in turn, feel uncomfortable sitting at a table where everyone is checking a smartphone instead of talking to each other. If this is the case, the benefits  of the dinner for NS players may be null or negative. At the same time, the impossibility of checking Facebook during face-to-face interactions-due, for example, to the moral obligation to talk-can make SN players feel uncomfortable and anxious . In this case, the benefits  of the dinner may be poor or even null or negative for SN players, too. As a result, SN and NS players might want to discriminate in face-to-face interactions. More generally, players' preferences for their similar type may be interpreted as a matter of homophily. Empirical literature has shown that informal segregation spontaneously emerges in relation to discrimination on the grounds of specific individual characteristics and/or as a result of peer pressure . SNS studies have shown that online social networks are so pervasive that they may well be considered as a crucial individual characteristic that prompts a negative bias towards non-users, and vice versa. 7 On the other hand, SN players may receive different payoffs when interacting with others of the same type, depending on whether the interaction takes place online or offline. Several experiments, in fact, have shown that people behave online in a very peculiar way as compared to face-to-face interaction. Kiesler et al. observed that computer-mediated communication entails anonymity, reduced self-regulation and reduced self-awareness. 'The overall weakening of selfor normative regulation might be similar to what happens when people become less self-aware and submerged in a group, that is, deindividuated . Deindividuation has, in turn, been found to be conducive to disinhibition and lack of restraint . Siegel et al. people in computer-mediated groups were more aggressive than they were in face-to-face groups, as measured by uninhibited verbal behavior. Deregulation and disinhibition encourage "online incivility", which includes aggressive or disrespectful behaviors, vile comments, online harassment, and hate speech. Antoci et al. argued that online incivility may be a major cause of frustration and dissatisfaction, which suggests that the benefits of the interaction between SN players could also be negative if the interaction takes place via SNS, and positive if the interaction occurs face-to-face. --- Evolutionary Dynamics We assume that the adoption process of strategies SN, NS and NP is determined by the well-known replicator equations in continuous time : 𝑥 1 ̇= 𝑥 1 𝑥 2 ̇= 𝑥 2 𝑥 3 ̇= 𝑥 3 where 𝑥 1 ̇, 𝑥 2 ̇, and 𝑥 3 ̇ represent the time derivatives of the functions 𝑥 1 , 𝑥 2 , and 𝑥 3 , respectively, and 𝐸𝑃 ̅̅̅̅ = 𝑥 1 𝐸𝑃 𝑆𝑁 + 𝑥 2 𝐸𝑃 𝑁𝑆 + 𝑥 3 𝐸𝑃 𝑁𝑃 is the population-wide average payoff of strategies. Dynamics are defined in the simplex S illustrated in Figure 1, where 𝑥 1 , 𝑥 2 , 𝑥 3 ≥ 0 and 𝑥 1 + 𝑥 2 + 𝑥 3 = 1 hold. The vertices of S, i.e., the vectors 𝑒 1 = , 𝑒 2 = , and 𝑒 3 = , correspond to the states in which all individuals adopt a unique strategy-respectively, SN, NS or NP. We denote 𝑒 𝑖 -𝑒 𝑗 the edge of S joining 𝑒 𝑖 with 𝑒 𝑗 ; thus 𝑒 1 -𝑒 2 is the edge where only strategies SN and NS are present in the population , 𝑒 1 -𝑒 3 is the edge where only strategies SN and NP are present, and 𝑒 2 -𝑒 3 is the edge where only strategies NS and NP are present. As usual with replicator dynamics, such edges are invariant sets. It is easy to check that dynamics can be written in the following form : 𝑥̇𝑖 = 𝑥 𝑖 , 𝑖 = 1, 2, 3 where 𝒙 is the vector 𝒙 = , and A is the payoff matrix: 𝐴 = 𝛼 + 𝛽𝑙 2 𝑛 2 + 𝛾𝑙 2 2 𝛼 + 𝛿𝑙 2 𝛼 𝛼 + 𝜀𝑙 2 𝛼 + 𝜂𝑙 2 𝛼 𝛼 𝛼 𝛼 ) We will analyze dynamics under the following assumptions: --- Assumption I 𝐸𝑃 𝑆𝑁 > 𝐸𝑃 𝑁𝑆 , i.e., 𝛽𝑛 2 + 𝛾 2 > 𝜀: the SN strategy is better performing than the NS strategy in a social context in which all individuals adopt the SN strategy . --- Assumption II 𝐸𝑃 𝑁𝑆 > 𝐸𝑃 𝑆𝑁 , i.e., 𝜂 > 𝛿 : the NS strategy is better performing than the SN strategy in a social context in which all individuals adopt the NS strategy . Assumption I establishes a minimal condition for segregation. This condition is always satisfied if  and , i.e., the benefits that SN players get when they interact online and face-to-face with other SN players, respectively, are positive and , i.e., the reward that NS players get when interacting with SN players face-to-face, is negative or equal to zero. In this case, SN players will discriminate against those who do not use online social networks, and NS players will not have any specific interest in engaging with them. More generally, Assumption I is satisfied if the value of  is sufficiently lower than  and , i.e., 𝜀 < 𝛽𝑛 2 / + 𝛾. Assumption II requires that the benefit  obtained by SN players that meet NS individuals face-toface is sufficiently lower than the benefit obtained by NS players when they meet face-to-face with individuals of their same type. This condition is certainly satisfied if   . In this case, NS players discriminate, in face-to-face encounters, against those who adopt the SN strategy. --- Results It is well-known that dynamics do not change if an arbitrary constant is added to all entries of a column of A . Therefore, we can replace matrix A in equations with the following normalized matrix B, with the first row made of zeros: 𝐵 = = = -𝛽𝑙 2 𝑛 2 -𝛾𝑙 2 2 𝜂𝑙 2 -𝛿𝑙 2 0 𝛼𝑙 -𝛽𝑙 2 𝑛 2 -𝛾𝑙 2 2 𝛼𝑙 -𝛿𝑙 2 𝑙𝛼 ) According to Assumptions I and II, 𝑎 < 0 and 𝑏 > 0 hold. Furthermore, 𝑓 > 0 always. The dynamic regimes that can be observed under Assumptions I and II can be classified taking into account the following results. --- Proposition 1 1) The stationary state 𝑒 1 is a sink if the following condition holds ): 𝑑 = 𝛼𝑙 -𝛽𝑙 2 𝑛 2 -𝛾𝑙 2 2 < 0 i.e., 𝛼 < 𝛽𝑙𝑛 2 + 𝛾𝑙 2 but it is a saddle point if does not hold 2) The stationary state 𝑒 2 is a sink if the following condition holds ): 𝑒 -𝑏 = 𝛼𝑙 -𝜂𝑙 2 <0i.e., 𝛼 < 𝜂𝑙 (6 ) but it is a saddle point if does not hold 3) The stationary state 𝑒 3 is always a sink. Proof: See the Mathematical Appendix A. Note that conditions and are simultaneously satisfied if the value of the parameter 𝛼 measuring the payoff of the NP strategy is low enough. Distinct from 𝑒 1 and 𝑒 2 , the stationary state 𝑒 3 is always a sink, whatever the value of the parameter 𝛼 > 0 is. When the pure population states 𝑒 1 , 𝑒 2 , and 𝑒 3 are sinks, they also are Nash equilibria . In such a case, they can be interpreted as stable social conventions representing self-enforcing configurations of the social environment. In our model, individuals' welfare evaluated at 𝑒 1 , 𝑒 2 , and 𝑒 3 is measured, respectively, by: 𝐸𝑃 𝑆𝑁 = 𝛼 + 𝛽𝑙 2 𝑛 2 + 𝛾𝑙 2 2 𝐸𝑃 𝑁𝑆 = 𝛼 + 𝜂𝑙 2 𝐸𝑃 𝑁𝑃 = 𝛼 The following proposition deals with Pareto dominance relationships among the stationary states 𝑒 1 , 𝑒 2 , and 𝑒 3 . --- Proposition 2 The stationary state 𝑒 1 Pareto dominates the stationary state 𝑒 2 > 𝐸𝑃 𝑁𝑆 ) if: 𝜂 < 𝛽𝑛 2 + 𝛾 2 and Pareto dominates the stationary state 𝑒 3 > 𝐸𝑃 𝑁𝑃 ) if: 𝛼 < 𝛽𝑙𝑛 2 + 𝛾𝑙 2 The stationary state 𝑒 2 Pareto dominates the stationary state > 𝐸𝑃 𝑁𝑃 ) if: 𝛼 < 𝜂𝑙 Proof: Straightforward. It is important to note that and coincide, respectively, with the stability conditions and . Therefore, if and only if 𝑒 1 and 𝑒 2 are sinks, they Pareto dominate the stationary state 𝑒 3 in which individuals withdraw from social participation. This implies that, in the context in which at least one of the stationary states 𝑒 1 and 𝑒 2 are sinks, the stationary state 𝑒 3 can be interpreted as a social poverty trap. In the trap, everyone withdraws from social participation and devote all of their available time to "private" activities, including work and consumption that does not entail any significant social relationship. The "social poverty" that derives from this situation-manifesting, for example, in the scarcity of participation opportunities and in the strengthening of materialistic values-makes social interaction difficult and unrewarding. Also note that the Pareto dominance relationship between 𝑒 1 and 𝑒 2 ) does not depend on the stability conditions and , and, consequently, 𝑒 1 may Pareto dominate 𝑒 2 or vice versa, independently of their stability properties. The following proposition concerns the existence and stability properties of the other possible stationary states of dynamics , i.e., the stationary states in which at least two among the available strategies, are adopted by positive shares of the population. --- Proposition 3 1) A unique stationary state in the interior of S , in which all strategies are played, exists if: 𝑎𝑒 -𝑏𝑑 = 𝑙 3 {𝜀[𝛼 -𝛿𝑙] + 𝛼𝛿} + +𝑙 3 {[𝛽𝑛 2 + 𝛾 2 ] -𝛼𝜂} > 0 Such a stationary state is always a source . If condition does not hold, then no stationary state exists in the interior of S. 2) A unique stationary state always exists in the edge 𝑒 1 -𝑒 2 of the simplex S ; it is a saddle point if the stationary state in the interior of S exists ; otherwise it is a source. 3) A unique stationary state exists in the edge 𝑒 1 -𝑒 3 if 𝑑 < 0 ) and it is always a saddle point . If 𝑑 ≥ 0, then no stationary state exists in 𝑒 1 -𝑒 3 . 4) A unique stationary state exists in the edge 𝑒 2 -𝑒 3 if 𝑒 -𝑏 < 0 ), and it is always a saddle point . If 𝑒 -𝑏 ≥ 0, then no stationary state exists in 𝑒 2 -𝑒 3 . Proof: See the Mathematical Appendix A. --- Classification of Dynamic Regimes Bomze provided a complete classification of two-dimensional replicator equations. The above propositions allow us to select, among all of the phase portraits illustrated in Bomze's paper, those that can be observed under dynamics . In Figures 2345678, sinks are indicated by full dots, sources are indicated by open dots and saddle points by drawings of their stable and unstable branches. The basins of attraction of 𝑒 1 , 𝑒 2 , and 𝑒 3 are rendered in yellow, blue and pink, respectively. According to Proposition 3 , every trajectory starting from an initial distribution of strategies 𝑥 1 , 𝑥 2 , and 𝑥 3 -neither belonging to a one-dimensional stable manifold of a saddle point nor coinciding with a stationary state in which more than one strategy is adopted-approaches one of the pure population stationary states 𝑒 1 , 𝑒 2 , and 𝑒 3 . In the following subsections, we will present the complete classification of the possible dynamics regimes that can be observed under . --- Regime One: Conditions and Hold In this context, all of the vertices 𝑒 1 = , 𝑒 2 = , and 𝑒 3 = are simultaneously attractive and the regimes illustrated in Figures 2 and 3 can be observed. The former -corresponding to the phase portrait number 35 in Bomze's classification-occurs when 𝑎𝑒 -𝑏𝑑 ≤ 0 ), while the latter-corresponding to PP#7-occurs when 𝑎𝑒 -𝑏𝑑 > 0. In this context, the stationary state 𝑒 3 = -in which all the individuals play the NP strategy-is Pareto dominated by the other locally attracting stationary states. This suggests that the NP strategy can be interpreted as an adaptive behavior that agents may want to play to protect themselves from situations of relational poverty and decay of the surrounding social environment. As clearly illustrated in Figures 2 and3, these regimes are strongly path dependent. If the initial distribution of the different forms of participation is close enough to 𝑒 1 = , i.e., if 𝑥 1 is high enough and 𝑥 2 and 𝑥 3 are low enough, then the economy converges to 𝑒 1 , and all individuals adopt the SN strategy. On the other hand, if the initial distribution is close enough to 𝑒 2 or 𝑒 3 , then the economy converges to 𝑒 2 or 𝑒 3 . Figure 2. Dynamic regime in which all of the vertices 𝑒 1 = , 𝑒 2 = , and 𝑒 3 = are simultaneously attractive and a stationary state in the interior of S does not exist. The basins of attraction of 𝑒 1 , 𝑒 2 and 𝑒 3 are rendered in yellow, blue and pink, respectively. Figure 3. Dynamic regime in which all of the vertices 𝑒 1 = , 𝑒 2 = , and 𝑒 3 = are simultaneously attractive and a stationary state in the interior of S exists. The basins of attraction of 𝑒 1 , 𝑒 2 and 𝑒 3 are rendered in yellow, blue and pink, respectively. --- Regime Two: Condition Holds, But Does Not Hold In this context, the vertices 𝑒 1 = and 𝑒 3 = are attractive, while 𝑒 2 = is a saddle point. The regimes are illustrated in Figures 4 and5. The regime in Figure 4-corresponding to PP#37 of Bomze's classification-occurs when 𝑎𝑒 -𝑏𝑑 ≤ 0 ), while the latter-corresponding to PP#9-occurs when 𝑎𝑒 -𝑏𝑑 > 0. In this context, the stationary state 𝑒 3 = in which all the individuals play the NP strategy is Pareto dominated by state 𝑒 1 = in which all the individuals play the SN strategy. Furthermore, the stationary state 𝑒 2 = in which all the individuals play the NS strategy is Pareto dominated by both the stationary states 𝑒 1 = and 𝑒 3 = . Figure 5. Dynamic regime in which only the vertices 𝑒 1 = and 𝑒 3 = are attractive, and a stationary state in the interior of S exists. The basins of attraction of 𝑒 1 and 𝑒 3 are rendered in yellow and pink, respectively. --- Regime Three: Condition Holds, But Does Not Hold In this context, the vertices 𝑒 2 = and 𝑒 3 = are attractive, while 𝑒 1 = is a saddle point. The regimes are illustrated in Figures 6 and7. The regime in Figure 6-corresponding to PP#37 of Bomze's classification-occurs when 𝑎𝑒 -𝑏𝑑 ≤ 0 ), while the latter-corresponding to PP#9-occurs when 𝑎𝑒 -𝑏𝑑 > 0. In this context, the stationary state 𝑒 3 = in which all the individuals play the NP strategy is Pareto dominated by state 𝑒 2 = in which all the individuals play the NS strategy. Furthermore, the stationary state 𝑒 1 = in which all the individuals play the SN strategy is Pareto dominated by both the stationary states 𝑒 2 = and 𝑒 3 = . --- Regime Four: Neither Condition Nor Hold In this context, 𝑎𝑒 -𝑏𝑑 ≤ 0 always holds , and the unique dynamic regime that can be observed is illustrated in Figure 8, corresponding to PP#42 of Bomze's classification. In this regime, the unique attractive stationary state is 𝑒 3 = , in which all individuals withdraw from social participation, which Pareto dominates both the stationary states 𝑒 1 = and 𝑒 2 = . This extreme scenario may be interpreted as the result of exogenous conditions of social decay, which make social participation poorly rewarding. For instance, the scarcity of infrastructures for face-to-face interactions lowers the reward provided by the NS strategy. Furthermore, the poverty of technological infrastructures for fast Internet access lowers the reward associated with the SN strategy. --- Discrimination and the Social Poverty Trap The classification of dynamic regimes illustrated in Figures 2345678suggests that the structure of the basin of attraction of the social poverty trap e3 crucially depends on the propensity for discrimination of the two sub-populations of socially active individuals. The higher the propensity for discrimination, the greater the probability that individuals will ultimately segregate themselves, making society fall into the trap. In fact, the less gratifying the interaction between SN and NS players, the more attractive the social isolation strategy NP becomes. If the rewards  and ε that SN and NS players get when they interact face-to-face is particularly low, then they both might be tempted to withdraw from social interaction, whatever the initial share of the sub-population adopting either SN or NS is. Notice that when condition holds, then a stationary state in the interior of the simplex S exists. This condition is never satisfied if the rewards  and ε are negative and low enough. In such a context, if the stationary states e1 and e2 are attractive , then the basin of attraction of the social poverty trap e3 is so large that it includes points close to the edge 𝑒 1 -𝑒 2 , where the NP strategy is almost extinct, the majority of the population socially participates and the two strategies of social participation are uniformly distributed. However, the basin of attraction of the social poverty trap e3 does not include the areas in close proximity to the edge 𝑒 1 -𝑒 2 if the rewards  and ε are high enough and, therefore, condition is satisfied . This result suggests that, if the two sub-populations of SN and NS players have a limited tendency to discriminate against each other-which happens if the rewards  and ε that the two types of players receive when they interact face-to-face are high enough-then society will be less likely to fall into the social poverty trap in the cases in which the initial level of social participation is high, even if the two strategies NS and SN are uniformly distributed, as happens in the dynamic regime illustrated in Figure 3. On the other hand, when the reward given by the interaction between SN and NS players is particularly low, the two strategies ultimately may crowd each other out. A similar crowding-out effect also applies to the dynamic regimes illustrated in Figures 4, 5, 6 and 7. In these cases, the basin of attraction of the social poverty trap e3 is so large that it also includes the areas in close proximity to the edge 𝑒 1 -𝑒 2 . This means that society can converge to e3 even if the initial share of the sub-population adopting the social participation strategies SN and NS is particularly high. --- Supplementary Result: A Prediction of the Model There is growing empirical evidence showing that face-to-face interaction is associated with higher levels of well-being than SNS-mediated interactions. Using Italian cross-sectional data, Sabatini and Sarracino found that subjective well-being is positively correlated with face-to-face encounters and negatively correlated with SNS-mediated interactions. Helliwell and Huang reached a similar conclusion by comparing the well-being effects of online and offline friendships If e1 and e2 are attractive, then the former can Pareto dominate the latter or vice versa, but in both cases the equilibria Pareto dominate the social poverty trap e3. The dynamic regimes are strongly path dependent. If the initial distribution of the three strategies is close enough to e1, then the economy will converge to e1. The same can be said for e2 and e3. The social poverty trap e3, on the other hand, is always a sink, whatever the payoff of social withdrawal. In this scenario, the withdrawal from social participation can be interpreted as a defensive behavior in the sense theorized by Hirsch . Individuals, in fact, might want to cope with the deterioration in the social environment surrounding them and/or with the increasing busyness related to their material aspirations by choosing to limit their social relationships to a minimum. This result is related to previous research that studied how growth may cause negative externalities on social relationships and social cohesion . These studies claimed that the rise in material aspirations and the need to work more might tighten time constraints, causing deterioration in the social environment and prompting a gradual withdrawal from face-to-face interactions. Social withdrawal is self-reinforcing, in that the higher the share of the population renouncing social participation, the poorer the social environment becomes, for example, in terms of social engagement opportunities. People playing the NP strategy will ultimately decide to segregate themselves from the rest of the population. In all of the possible cases corresponding to the stationary states e1, e2 and e3, the segregation entailed by individuals' tendency for discrimination will lead to the survival of only one of the initial sub-populations. The model also allowed us to study the future of social participation in a world in which social interaction via online networks is less rewarding than offline interaction. This scenario is particularly interesting as it is consistent with findings from the most recent empirical studies comparing the effect of face-to-face and SNS-mediated interactions on individuals' well-being. Our results suggest that dynamics starting from this scenario will lead the SN strategy to extinction, which entails that Facebook and similar platforms will disappear. If we interpret the NS strategy more flexibly as a means of social participation demanding a minimum, instead of a null, interaction via SNS , then the possible equilibria-existing in e2, e3 or in the edge between them-entail at least a dramatic reduction in the use of Facebook and other platforms, instead of their definitive disappearance. According to equation = /) , exists if and only if 𝑎𝑒 > 𝑏𝑑 of Proposition 3). The Jacobian matrix of system -, evaluated at , is a triangular matrix: 𝐽 = With eigenvalues 𝑏𝑋 ̅ > 0 and 𝑓𝑌 ̅ > 0. So is always a repulsive node . By following similar steps, it is easy to verify that: 1) The Lotka-Volterra system - always admits a unique stationary state = ⁄ , with -𝑎/𝑏 > 0, belonging to the positive semi-axis 𝑌 = 0 . Such a stationary state is a saddle point if the internal stationary state exists; otherwise it is a source . 2) The Lotka-Volterra system - admits a unique stationary state = , with -𝑑 𝑓 ⁄ > 0, belonging to the positive semi-axis 𝑋 = 0 if 𝑑 < 0. Such a stationary state is always a saddle point with unstable manifold lying in 𝑋 = 0. If 𝑑 ≥ 0, then no stationary state with 𝑌 > 0 exists in the positive semi-axis 𝑋 = 0 . 3) The state = is always a stationary state; it is a saddle point if 𝑑 ≥ 0 , otherwise it is a sink . The stability properties of the stationary states 𝑒 2 and 𝑒 3 and the existence and stability properties of the stationary state belonging to the edge 𝑒 2 -𝑒 3 8 can be easily analyzed by applying Propositions 1, 2 and 5 in Bomze , who provided a complete classification of two-dimensional replicator equations. --- Mathematical Appendix B The condition: 𝐸𝑃 𝑆𝑁 > 𝐸𝑃 𝑁𝑆 can be written as follows: Along the straight line , 𝑋 ̇= 0 holds, while the set in which 𝐸𝑃 𝑆𝑁 < 𝐸𝑃 𝑁𝑆 holds corresponds to the region on the right of . Since cannot be crossed by trajectories , the two regions separated by are invariant. Consequently, every trajectory starting from the region in which 𝐸𝑃 𝑆𝑁 < 𝐸𝑃 𝑁𝑆 cannot converge to the stationary state = , which corresponds to the stationary state 𝑒 1 = . This completes the proof of Proposition 4. 𝑎𝑥 1 + 𝑏𝑥 2 < --- in a Canadian sample. Kross et al. examined this issue using experience sampling. The authors text-messaged people five times per day for two weeks to test how offline and Facebookmediated interactions correlate with aspects of subjective well-being . Results indicate that Facebook use predicts negative shifts in SWB, while face-to-face interactions show no significant effect. Based on a survey conducted on a representative sample of 2,000 French Facebook users, Pénard and Mayol found that Facebook interferes with subjective well-being through its effects on friendships and self-esteem. Their results show that people who also use the network to seek social approval in the form of more "likes" tend to be more unsatisfied with their life. Similarly, Sabatini and Sarracino drew on Italian representative data to show that the use of SNS is associated with lower levels of satisfaction with respondents' income, which was not found to be the case from face-to-face interactions, thereby suggesting that the use of online networks can raise material aspirations with detrimental effects for SWB. Overall, the empirical evidence suggests the utility of further analyzing the dynamics occurring in the region of the simplex where: In this region, the reward provided by a strategy of social participation exclusively based on faceto-face interactions is higher than the benefits associated with the use of SNS . The following proposition allows for the prediction of the possible evolution of the shares of the population 𝑥 1 , 𝑥 2 , 𝑥 3 adopting the three strategies in a society, starting from an initial configuration of payoffs that are consistent with the evidence mentioned above, where: The set in which holds and the set in which holds are invariant under dynamics . That is, every trajectory starting from the former cannot enter the latter, and vice versa. Proof: See the Mathematical Appendix B. Proposition 4 states that if the payoff associated with the NS strategy is initially higher than that associated with the SN strategy, then it will always be higher than that provided by the SN strategy, unless exogenous perturbations change the model's parameters. As a result, the economy cannot converge to the stationary state 𝑒 1 = , in which all individuals adopt the SN strategy, if it is starting from the region in which 𝐸𝑃 𝑁𝑆 > 𝐸𝑃 𝑆𝑁 holds. This means that almost all of the trajectories starting from such a region will converge to e2, in which individuals socially participate by exclusive means of face-to-face interactions, or to e3, in which nobody participates. Only one trajectory can reach the edge 𝑒 2 -𝑒 3 where the NS and the NP strategies coexist. In any case, the analysis of dynamics suggests that society will converge to equilibria in which no one adopts the SN strategy. --- Conclusions In this paper, we developed an evolutionary game model to study the dynamics of different modes of interaction in contexts characterized by the steep rise in the use of SNS and a supposed decline in face-to-face social participation. In our framework, individuals can choose to withdraw from social relations or to interact with others online and offline. The analysis showed that, depending on the configuration of payoffs and the initial distribution of the various modes of participation in the population, different Nash equilibria could be reached. If we allow a configuration of payoffs that is compatible with individuals' preference for similar others, then discrimination will lead to the segregation of the three sub-populations accounted for in the analysis and, ultimately, to the survival of only one of the three. Every trajectory that starts from an initial distribution of strategies neither belonging to a one-dimensional stable manifold of a saddle point nor coinciding with a stationary state in which more than one strategy is adopted will approach one of the homogenous population stationary states. If the reward for social withdrawal is low enough, then the stationary states in which all individuals play one of the two strategies of participation, e1 and e2, are locally attractive. In this case, they both Pareto dominate the stationary state in which everyone withdraws from social interaction, e3. However, there is no Pareto dominance relationship between e1 and e2. --- Compliance with ethical standards The research of Angelo Antoci and Fabio Sabatini has been funded by Regione Autonoma della Sardegna in the context of the research project "Social capital and growth differentials". The authors declare that they have no conflict of interest. --- Mathematical Appendix A Dynamics is equivalent to the Lotka-Volterra system: 𝑌 ̇= 𝑌 via the coordinate change: From which 𝑋 = 𝑥 2 𝑥 1 ⁄ and 𝑌 = 𝑥 3 𝑥 1 ⁄ . Please note that by the coordinate change , the edge 𝑒 1 -𝑒 2 of the simplex S corresponds to the positive semi-axis 𝑌 = 0 of the plane , the edge 𝑒 1 -𝑒 3 corresponds to the positive semi-axis 𝑋 = 0 and the vertex 𝑒 1 corresponds to the point = .

There is growing evidence that face-to-face interaction is declining in many countries, exacerbating the phenomenon of social isolation. On the other hand, social interaction through online networking sites is steeply rising. To analyze these societal dynamics, we have built an evolutionary game model in which agents can choose between three strategies of social participation: 1) interaction via both online social networks and face-to-face encounters; 2) interaction by exclusive means of face-to-face encounters; 3) opting out from both forms of participation in pursuit of social isolation. We illustrate the dynamics of interaction among these three types of agent that the model predicts, in light of the empirical evidence provided by previous literature. We then assess their welfare implications. We show that when online interaction is less gratifying than offline encounters, the dynamics of agents' rational choices of interaction will lead to the extinction of the sub-population of online networks users, thereby making Facebook and similar platforms disappear in the long run. Furthermore, we show that the higher the propensity for discrimination of those who interact via online social networks and via face-to-face encounters (i.e., their preference for the interaction with agents of their same type), the greater the probability will be that they all will end up choosing social isolation in the long run, making society fall into a "social poverty trap".

INTRODUCTION There are nearly two million runaway and homeless youth in the USA each year. 1 Relative to housed youth, these youth are at increased risk for a myriad of health and behavioral health problems, including substance abuse, sexually transmitted diseases, poor mental health outcomes, violence, and victimization. [2][3][4][5] Recent work among homeless adults has suggested that cell phone technology may present unique opportunities for working with transient populations. 6 As cell phones offer connections to others without the physical constraints of permanent dwellings, new communication patterns are feasible for homeless people, including access to social support, case management, and health professionals, which could in turn lead to improved health and behavioral health outcomes. 6 To date, no data has been reported on the use of cell phone technology among homeless youth, although recent data has shown that 85% of homeless youth get online at least once a week, that they access a wide spectrum of network ties, and that connecting Rice, Lee, and Taitt are with the University of Southern California, Los Angeles, CA, USA. Correspondence: Eric Rice, University of Southern California, Los Angeles, CA, USA. to family and home-based friends was associated with improved sexual health outcomes. 7 Among housed youth, latest statistics from Pew Research Center 8 found 71% of teens and 93% of young adults own cell phones. Housed youth are now connected to their networks in constant and immediate ways. 9,10 Cell phones have changed the ways adolescents conceptualize belongingness and social connection, 11 creating new avenues for social support 10,12 and coping with stressful life events. 13 Young female adolescents and parents report increased feelings of security as a result of cell phones. 14,15 Some research suggests that merely owning, and not actually using, a cell phone helped adolescents to feel socially connected. 16 The purpose of this study was to conduct a preliminary examination of cell phone ownership and use among a sample of homeless youth, particularly the social and instrumental uses of cell phones which have implications for health outcomes. --- METHODS All procedures involving research on human subjects was approved by the university Institutional Review Board and conformed to the principles embodied in the Declaration of Helsinki. A non-probability sample of 201 adolescents was recruited June 2009 in Los Angeles, California at one drop-in agency serving homeless adolescents. Clients age 13 to 24 years were eligible to participate. A consistent set of two research staff conducted all recruitment and assessment to prevent adolescents completing the survey multiple times. If a youth reported living in a housing situation for 6 months or more they were excluded from the analyses, yielding the final sample of 169. The survey was anonymous and youth were read a consent form which they did not sign. Because homeless youth under the age of 18 are by definition unaccompanied minors, a waiver of parental consent was obtained for minors from the IRB. The survey was a computer-administered self-interview, delivered at the agency, lasting 60 minutes. Participants received a $20 gift card. Exact wording for cell phone use variables are reported on Table 1. All variables in Table 2 were based on self report. Chi-square and t test statistics were used to assess differences between cell phone owners and non-cell phone owners across demographic, substance use , 18 mental health , and housing characteristics . 21 --- RESULTS Overall 62% of youth owned a cell phone: 40% owned a working phone, 15% owned a phone with no minutes, and 7% shared a phone with a friend. Moreover, 62% of youth reported using a cell phone at least once a day. Only 22% reported having no cell phone access at all. The most common route of procurement was from money earned at a job, followed by receiving a phone as a gift, and acquiring money through pan-handling. Youth reported using their cell phones to connect to a wide array of social network ties. The most frequently endorsed tie type was friends from home, followed by parents, siblings, and street-based peers. Of particular interest is the number of youth using their phones for instrumental purposes: 17% reported using a cell phone to contact case workers, social workers, or staff at youth agencies; 24% reported using their cell phone to contact a potential employer; and 12% to a current employer. As presented in Table 2, there were almost no significant differences between those youth who owned a cell phone and those who did not with respect to demographic characteristics, life experiences, recent substance use, or mental health. The exception was that significantly more lesbian/gay/bisexual/unsure youth owned phones relative to heterosexual youth, youth sleeping on the streets reported less cell phone ownership than youth in shelters or in temporary housing, and youth who owned phones were slightly older on average. --- DISCUSSION These data include several novel findings. First, 62% of homeless youth sampled had a cell phone and a comparable number reported using a cell phone at least once per day. Only 22% of the youth sampled reported having no access to a cell phone. While this level of use and ownership is less than that reported among housed adolescents, 8 the rates are high. We caution readers that these results come from a non-probability sample collected at one drop-in agency in Los Angeles, and should not be generalized to dissimilar settings. Second, as was the case with homeless adults, 6 there were not many socio-demographic differences in the backgrounds of persons who reported cell phone ownership relative to those who did not. An important exception was that more youth who reported staying in shelters or temporary housing also reported owning a cell phone relative to youth actively sleeping on the streets. Our conjecture is that access to financial resources is the salient issue, but as we did not collect information on income, we can only proffer this as a possible explanation. Youth used their cell phones to access a spectrum of different network ties. Approximately half of youth used their phones to connect to home-based peers and approximately 40% connected with parents and other family members via their phones. Cell phones may enable homeless youth to more effectively access family and home-based support networks in times of need or crisis. Social support has well established connections to a wide array of positive physical and behavioral health outcomes. 22 Using a cell phone to access support networks has been documented among housed youth 12,13,23 and these data suggest that while the life circumstances of homeless youth differ, they are also using their cell phones to access networks which have the potential to provide social support. These data also show that youth are using cell phones for instrumental purposes related to homelessness. Many youth reported using a cell phone to communicate with a case manager or social worker, and to contact potential or current employers. Cell phone access is not merely a resource unto itself, but a relatively cheap resource which can enable youth to pursue higher level resources, such as housing and employment. We challenge the reader to imagine trying to secure a job or a place to live without access to a phone. Homeless youth are no different. Having a cell phone allows these youth to more effectively search for jobs and housing, which in turn can lead to stability. Thus, cell phones may provide new opportunities for linking youth to resources and care which can improve their physical and behavioral health outcomes. Limitations to the study included self-reported cell phone use, cross sectional data, and a non-probability sampling strategy. Also, we do not differentiate between face-to-face and cell phone-accessed networks, and face-to-face networks may be more important sources of support and influence. While preliminary, these data suggest new opportunities for research and service delivery for homeless youth. Many of these youth have mobile phones and as such, there are new opportunities for case managers and social workers to maintain sustained contact with them despite their transient life-styles. Moreover, that youth are using their cell phones to access networks which can provide social support in times of need opens the possibility for developing intervention programs for homeless youth which focus on accessing these possible sources of support. Typically, interventions for homeless youth ignore their ongoing relationships to family and home-based peers, 24 yet research has demonstrated that sexual risk taking and substance use are reduced when youth continue to access these networks. 7,25 Cell phones may be a way to keep these youth more regularly and more meaningfully engaged with these physically distant but emotionally close relationships, which could promote positive health outcomes.

Cell phone use has become nearly ubiquitous among adolescents in the United States. Despite the potential for cell phones to facilitate intervention, research, and care for homeless youth, no data exists to date on cell phone use among this population. In 2009, a survey of cell phone use was conducted among a nonprobability sample of 169 homeless youth in Los Angeles, CA. Levels of ownership and use, instrumental uses (connecting to case workers, employers) and patterns of connecting to various network types were assessed (family, home-based peers, streetbased peers). Differences in socio-demographic characteristics and cell phone ownership were assessed via t test and chi-square statistics. Sixty-two percent of homeless youth own a cell phone; 40% have a working phone. Seventeen percent used their phone to call a case manager, 36% to call either a potential or current employer. Fifty-one percent of youth connected with home-based peers on the phone and 41% connected to parents. Cell phones present new opportunities for intervention research, connecting homeless youth to family and home-based peers who can be sources of social support in times of need. Moreover, cell phones provide researchers and providers with new avenues to maintain connections with these highly transient youth.

nature of a self-fulfilling prophesy: 1. I cannot accomplish real life goals like normal people; 2. Nothing good will come of my life; 3. I'm not worthy; and 4. Nobody will help me. While incarceration perpetuates dysfunction and negative psychological effects, connecting to higher education causes a significant shift. After enrolling in college, attending class, challenging my current thought processes, doing homework and successfully completing that class, I experienced a dramatic change. I realized that I was able to learn. I was smarter than I thought. I could start and finish something. I became entrenched in learning about the psychology of incarceration and self-limiting beliefs, taking additional classes, increasing engagement with clinical and nonclinical programming and prosocial activities, while hoping people like me could break the cycle of recidivism and realize momentous life goals "like normal people". --- CUFFS TO CAREERS hen transferred to the state work release center, I requested delaying my release to continue my education on campus at Metropolitan Community College . Prison seems like a more intimidating environment than a college campus, yet coming to school as someone currently incarcerated was daunting. What if I get lost? What do I do between classes? Do people know who I am? Will they be afraid of me, if they find out? Thankfully, another incarcerated student directed me to the MCC TRiO Program to request a free bus pass to commute from prison to campus. The Federal TRiO Programs are student service programs for first generation college students and individuals from disadvantaged backgrounds. For the next year, this office became my safe haven on campus. Because of my poor self-image and fear that someone may realize I was still incarcerated, I was not comfortable in the traditional campus study areas. Being able to go to the TRiO office to study and volunteer, while the staff encouraged me to persist was impactful. A member of the TRiO team even attended my parole hearing to testify on my behalf. I had never known this level of support. When released, I inherently understood I could not return to my reservation or live with family as I may eventually return to old behaviors and recidivate. However, on the surface, staying in Omaha seemed counterproductive. I had no job, no money, no vehicle. I was new to the rooms of recovery so the only support I had were MCC employees. I was paroling to a transitional home to live with nine women in similar predicaments. Yet, again, I instinctively knew this would be the best plan. Soon after my prison release, I was employed by MCC to work part time in the TRiO area. I continued my education, worked three part time jobs and, informally, helped people from the state work release center enroll in classes, apply for scholarships and financial aid, and navigate MCC systems. I was taking a risk associating with the incarcerated. When on parole, a typical condition of parole is that you will not associate with others who have a criminal history or are still incarcerated. Even though I was on parole and this was a technical violation, I viewed it to be my responsibility to help my peers. --- W --- While incarceration perpetuates dysfunction and negative psychological effects, connecting to higher education causes a significant shift. MCC offers opportunity without disparity between those who have a criminal background and those who don't, as evidenced by my hiring. I had assumed two part time positions but was eventually hired as a full-time employee and was beyond grateful. I promised to never forget where I came from by continuing to help others and never leave MCC. Through the years, I worked in Student Affairs, Adult Education and Academic Affairs. When MCC applied for state funding to formalize the prison education program, I was managing an off-campus location and solely supporting 120 incarcerated and re-entry students. In 2015, I was appointed the Program Manager of the MCC 180 Re-entry Assistance Program , leading a team of 2 full time and 3 part time team members. In the first 17-month grant cycle, we served over 1,000 people. This prompted MCC to relocate 180 RAP to the main Fort Omaha Campus to cohabitate a building with Adult Education. This move connected re-entry students to vital student support, such as tutoring and the math and writing centers. e-entry campus traffic was tracked beginning April 2017 and averaged 5.3 students each day. By the end of 2018, traffic averaged 12.4 students each day causing adult education to be moved to another site to provide greater access and support for 180 RAP. During that year it is believed that MCC was hosting the largest on campus Re-entry Center in the United States. In 2021, the Re-entry Center was moved to an even larger building that doubled space availability to house a re-entry specific education center, job center, pantry, computer center, digital training lab and expanded commons and study areas. Foot traffic in the new Re-entry Center averaged 23.8 students per day in 2022 and continues to build each month. The job center served 1,128 in 2019 with an 80% employment rate, compared to 2,328 served in 2022 with a 97% employment rate. While MCC's focus was to provide higher education in Nebraska prisons, realizing the needs and removing barriers for incarcerated and re-entry students became a fundamental part of 180 RAP. How could we expect our students to focus on educational goals when they did not know where to go when released, were hungry, or couldn't find a job? An essential component of our work is based on the science of re-entry and focuses on identifying each individual's most salient criminogenic needs that might be barriers to their re-entry journey. By "criminogenic needs," we refer to factors that are directly related to criminal behavior but are changeable and can be addressed by programming . The eight central categories of criminogenic needshistory of antisocial behavior; antisocial cognition; antisocial associates; antisocial personality; family/marital instability; employment/education; substance abuse; leisure and recreationare integral to consideration of how to best support someone pre-and post-release. While some criminogenic needs are easy to address and navigate, identifying and understanding needs are central to assisting. For example, if someone is struggling to find employment yet creates and submits a suitable resumé and masters interviewing skills to obtain a job, their risk changes quickly as they enter the workforce gainfully employed. Other risks may be more complicated. For example, if someone is struggling with filling in their spare time with appropriate leisure and recreational activities and returning to old behaviors and poor choices, yet not motivated to address the behavior associated with the need, they may be slow to change risk levels, if at all. --- R --- How could we expect our students to focus on educational goals when they did not know where to go when released, were hungry, or couldn't find a job? With awareness of criminogenic needs, experiential participation in prison education programming and primary knowledge of the transitional experience from prison to the community, it is an uncomplicated process to identify key methods of support pre-and post-release: basic needs acquisition, viable access to education and employment services, and ongoing peer support and mentoring. In addition to a focus on criminogenic needs, peer-based support systems utilized by MCC 180 RAP since 2015 have proven to be a dependable model. Staffing 180 RAP with team members directly impacted by the justice system is important. As the peer ushers a student from intake to achieve their education and employment goals, they can communicate and address concerns more effectively than someone without lived experience in the justice system. Transition support offered vary on individualized needs screened by peer support mentors at intake and are revisited regularly throughout their journey. Basic needsfood, hygiene, diapers, laundry detergent, transition backpacks, bus passes, cell phonesare provided when released from jail or prison. For example, Christina faced many barriers when released and shared, "After 16 years in prison, everything scares you. 180 RAP did everything from helping me find housing…they gave me rides to school, showed me how to use a cell phone and computer, taught me how to interact with people and realize that everything is okay." Christina, known as "The Glue" of the team, is a full-time peer mentor who daily provides encouragement and support for people leaving Nebraska jails and prisons. Access to immediate needs reduces the likelihood of return to a base criminal activity to acquire those necessities. If seeking employment, the job center helps create resumés, provides workreadiness skill building, offers employment referrals to 360 employer partners in every industry and pay scale, and assists with workforce needsuniforms, footwear, tools, etc. Those choosing to continue formal education or short-term training are scheduled for one-on-one appointments with the education center team to register for classes or referred to the Re-entry job center to find employment. Connecting students to basic needs, education, employment, and other resources helps lower barriers when facing release without support. Peer support groups are valuable to the incarcerated and re-entry populations. An inclusive environment to ask questions and share concerns and wins is an enormous benefit to the personal growth and long-term stability of the individual. 180 RAP tracked 106 high risk individuals involved in a peer support group for 18 months, and 96% of those involved did not reoffend or return to prison. --- I AM NOT DOING IT ALONE = OTHER FORMERLY INCARCERATED/JUSTICE-INVOLVED PEOPLE AT RAP group of like-minded persons, all with their own histories of justice-involvement, are essential collaborators on my journey. For example: Greg, currently housed at the state work release center, had some of the same concerns and questions I did when he began attending class on campus as an incarcerated student after 25 years in prison. Greg, who began his education in MCC's prison education A --- A group of likeminded persons, all with their own histories of justice-involvement, are essential collaborators on my journey program in 2018, said, "I wasn't going to tell anyone I was incarcerated but I know now there's no discomfort or shame in it. Education has helped me learn how to pivot. I'm infused with reentry; it holds me up. It's a part of my spine. Someone went in front me, did the work, to provide me with the help that I wished that person had when they were coming out. To be grateful for that, I wear it as a badge of honor. The peer support from the Re-entry advisors and coaches have helped a lot…I just had to get some advice this morning." Greg was recently hired as a peer mentor with 180 RAP and moved to a full time Re-entry position in June. Sharri, Re-entry Program Manager at MCC 180 RAP, values how she has been able to utilize her lived experience to assist the justice impacted population in Nebraska. Sharri enters the prisons to connect students to Second Chance Pell education funding and manages the Full Turn team that provides transition support. Sharri said, 'The fulfilment of helping others -there's nothing better. It's easy to trace back to my life where people, who had like-minded experiences, stepped up and helped me. It helped me move forward and understand that my life would be okay, and I could change. Now I'm blessed with the opportunity to provide that same support to others." Empowering and motivating a marginalized population, while ensuring they are focused on both a personal and team mission, is impactful. Providing a mission to support the program helps them while they are accomplishing new goals, also helps others to see they do not have to be what they always were. This philosophy helped build the re-entry and prison education program at Metropolitan Community College. It's been 8 years since 180 RAP began and the life changing results from involvement in education, transition and peer support are evident. Since February 2015, 180 RAP has helped 8,930 people in prison or returning to the community. --- PRISON EDUCATION LESSONS LEARNED IN PRISON TRANSLATE TO THE STREET ast forward 20 years and, as Director of the Re-entry Program at the same college I took my first college credit class at while incarcerated, the lessons have been exponential: •Education during incarceration is the key to a deeper freedom than any prison release can offer. While it is an important fact that higher education in prison lowers recidivism rates, changing the long-term self-concept is integral to helping the incarcerated population succeed and grow as motivations, attitudes and behaviors mutate. •Ongoing peer support is a critical need for those impacted by the criminal justice system. No one can address another person more succinctly than someone with a mutual lived experience. Defenses and justifications diminish, and trust is earned quickly. •Transition assistance is mandatory for all releasing from an institution. We adopt a strength-based approach for motivating and empowering individuals, known as motivational interviewing . MI allows for individualized support, open communication, and acceptance of team-based approaches that drives the individual to connect to a personal and team mission, while receiving assistance with basic needs, education, employment and other transition services with dignity. --- F •True change can transpire if we live outside our comfort zone, seek support and help others. The program philosophy is "a hand up, not a handout". When individuals accept, they are part of a team and helping, while receiving help, changes the dichotomy of engagement. There is no humiliation receiving assistance when assisting. --- MOVING FORWARD My two favorite words are moving forward. I use these words dailyto remind myself and others I have the honor to serve that anything is possible. Motivating others is imperative. In retrospect, I am confident the educator that took the chance to stop a stoic, detached woman on the yard and talk about the possibilities with higher education understood the power of her words. While it cost her nothing, it was worth everything to me. Today I follow her lead. Whether I am talking to one of our students on campus or inside a Nebraska prison, I remind each person that engaging in higher education raises the likelihood of their success when released from prison. If they don't buy that, I tell them my story…and they listen.

EDUCATED BY THE SCHOOL OF HARD KNOCKS hinking back to that day in early 2001, I had no idea how much my life's trajectory would significantly shift. While walking across a prison yard, I was stopped by an educator at Nebraska Correctional Center for Women who suggested I enroll in a college class. The instructor realized my suspicion, so she relayed that she had reviewed my intake assessments and thought I might be a good candidate for higher education. The interaction was disturbing; why would this person I had never met approach me like she knew me? I was dubious, her audacity initially provoked anger yet, eventually, curiosity. I then submitted a request to the prison's education department asking to learn more about higher education opportunities at the prison, resulting in my enrollment in my first college credit class. Being an enrolled member of a Native American tribe, I was eligible for funding to attend college after I completed high school. Even though I had successfully completed high school, I unfortunately did not believe I could succeed in that environment. I was afraid to even talk about going to college with anyone. I did not feel like I had support, so I resigned myself to the thought that things like a college degree were not intended for people like me. The barriers I faced preincarceration were the same barriers I faced in accessing prison education programs, the cyclical T